Bell palsy - Clinicals, Diagnosis, and Management

Neurology

Clinicals - History

Fact Explanation
Acute weakness of one side of the face is the commonest presenting complaint muscles of facial expression are supplied by the facial nerve.unilateral, acute paresis or paralysis of the lower motor neuron facial nerve causes the sudden onset weakness. Acute weakness of one side of the face is the commonest presenting complaint
muscles of facial expression are supplied by the facial nerve.unilateral, acute paresis or paralysis of the lower motor neuron facial nerve causes the sudden onset weakness.
Eye problems[ Acute paresis or paralysis of orbicularis oculi caused by dysfunction of the lower motor neuron. Eye problems[
Acute paresis or paralysis of orbicularis oculi caused by dysfunction of the lower motor neuron.
Loss of ability to taste. Taste fibers to anterior two thirds of the tongue originate in the nucleus of the tractus solitarius (NTS), these fibers travel with the facial nerve and are given off as the chorda tympani,So facial nerve paralysis results in impaired /loss of taste over anterior part of the tongue., Loss of ability to taste.
Taste fibers to anterior two thirds of the tongue originate in the nucleus of the tractus solitarius (NTS), these fibers travel with the facial nerve and are given off as the chorda tympani,So facial nerve paralysis results in impaired /loss of taste over anterior part of the tongue.,
Increased sensitivity to sound. The nerve to stapedius arises from the facial nerve to supply the stapedius muscle. Stapedius muscle contract in response to loud sound which impairs the conduction/ reduces the intensity of Sound paralysis of stapedius causes hypersensitivity to common everyday sounds, perceived as unbearable, strong or painful [hyperacusis]. Increased sensitivity to sound.
The nerve to stapedius arises from the facial nerve to supply the stapedius muscle. Stapedius muscle contract in response to loud sound which impairs the conduction/ reduces the intensity of Sound paralysis of stapedius causes hypersensitivity to common everyday sounds, perceived as unbearable, strong or painful [hyperacusis].
Numbness in the affected side of your face. Unilateral, acute paresis or paralysis of facial movement caused by dysfunction of the lower motor neuron. Numbness in the affected side of your face.
Unilateral, acute paresis or paralysis of facial movement caused by dysfunction of the lower motor neuron.
Drooling Acute paresis or paralysis of facial movement caused by dysfunction of the lower motor neuron. Drooling
Acute paresis or paralysis of facial movement caused by dysfunction of the lower motor neuron.

Clinicals - Examination

Fact Explanation
Muscle function examination Extra temporal segment of facial nerve temporal, zygomatic, buccal, mandibular marginal and cervical supply the muscles of facial expressions. In bell s palsy patient will present with inability to furrow the forehead, drooping of the mouth, loss of nasolabial fold of the affected side Muscle function examination
Extra temporal segment of facial nerve temporal, zygomatic, buccal, mandibular marginal and cervical supply the muscles of facial expressions. In bell s palsy patient will present with inability to furrow the forehead, drooping of the mouth, loss of nasolabial fold of the affected side
Ocular examination: Inability of tight closure of the eye and on attempted closure, the eye rolls upward (Bell's phenomenon) The eyelids will not close and the lower lid sags Orbicularis oculli is supplyes by zygomatic branch of facial nerve Ocular examination: Inability of tight closure of the eye and on attempted closure, the eye rolls upward (Bell's phenomenon)
The eyelids will not close and the lower lid sags Orbicularis oculli is supplyes by zygomatic branch of facial nerve
Otoscopy examination: Thick fluid in the middle ear, perforation of tymphanic membrane chronic otitis media causes secondary facial nerve palsyOtoscopy is mandatory in all patients presenting with facial
paralysis
Otoscopy examination: Thick fluid in the middle ear, perforation of tymphanic membrane
chronic otitis media causes secondary facial nerve palsyOtoscopy is mandatory in all patients presenting with facial
paralysis
Oral examination: taste fibres of anterior part of the tongue is carried via facial nerve.In bell' s palsy ,oral examination will reveal impaired taste over anterior part of the tounge9 usulayy complaints of metallic taste Oral examination:
taste fibres of anterior part of the tongue is carried via facial nerve.In bell' s palsy ,oral examination will reveal impaired taste over anterior part of the tounge9 usulayy complaints of metallic taste
Neurological examination: Mainly cranial nerves The first step in the diagnosis is to determine whether facial weakness is upper motor neurone type or lower motor neurone type .LMN type involves all the facial muscles ipsilateral to the side of facial nerve involvement where as in UMN lesion involves lower facial muscles contralateral side.In bell s palsy there should be an isolated facial nerve palsy. there for complete neurological examination is necesary. Stroke is a secondary cause for facial nerve palsy Neurological examination: Mainly cranial nerves
The first step in the diagnosis is to determine whether facial weakness is upper motor neurone type or lower motor neurone type .LMN type involves all the facial muscles ipsilateral to the side of facial nerve involvement where as in UMN lesion involves lower facial muscles contralateral side.In bell s palsy there should be an isolated facial nerve palsy. there for complete neurological examination is necesary. Stroke is a secondary cause for facial nerve palsy
Systemic examination: Elevated blood pressure Hypertension is a rare but well recognised cause of facial paralysis Systemic examination: Elevated blood pressure
Hypertension is a rare but well recognised cause of facial paralysis

Investigations - Diagnosis

Fact Explanation
Full Blood Count Facial paralysis is a recognised feature of leukaemic
recurrence in both adults and children. A small number of cases of facial paralysis in children occur as a presentation of leukaemia.
Full Blood Count
Facial paralysis is a recognised feature of leukaemic
recurrence in both adults and children. A small number of cases of facial paralysis in children occur as a presentation of leukaemia.
Thyroid function test bells palsy has been reported in association with hypothyroidism Thyroid function test
bells palsy has been reported in association with hypothyroidism
Lyme antibody titers if the patient's history suggests possible exposure. Lyme antibody titers
if the patient's history suggests possible exposure.
Serum titers of herpes simplex virus Herpes simplex and varicella zoster viruses have been
implicated in the pathogenesis of idiopathic facial palsy.
Serum titers of herpes simplex virus
Herpes simplex and varicella zoster viruses have been
implicated in the pathogenesis of idiopathic facial palsy.
VDRL, HIV screening Syphilis and HIV are infective causes for idiopathic facial palsy VDRL, HIV screening
Syphilis and HIV are infective causes for idiopathic facial palsy
Shimmer test due to denervation of lacrimal glands, patients are suffering from dry eyes Shimmer test is used for qualitative assessment of tear production.this test is cheap and easy to perform Shimmer test
due to denervation of lacrimal glands, patients are suffering from dry eyes Shimmer test is used for qualitative assessment of tear production.this test is cheap and easy to perform
Salivary flow metry parasympathetic innervation of salivary glands is carried via facial nerve. in bell s palsy there is reduced salivation. bells palsy can be detected by salivary flowmetry early as within 48 hours of onset. Also it has a prognostic value Salivary flow metry
parasympathetic innervation of salivary glands is carried via facial nerve. in bell s palsy there is reduced salivation. bells palsy can be detected by salivary flowmetry early as within 48 hours of onset. Also it has a prognostic value
Neurophysiological tests: EMG fibrillation potentials in muscle indicates axonal degeneration which can be detected by EMG. Approximately after 3 months from onsetof bell s palsy, this can be detected. it also has a prognostic value Neurophysiological tests: EMG
fibrillation potentials in muscle indicates axonal degeneration which can be detected by EMG. Approximately after 3 months from onsetof bell s palsy, this can be detected. it also has a prognostic value
CSF analysis CSF investigations may show pleocytosis, increased or decreased glucose, increased protein, antibodies against viruses or against Borrelia burgdorferi, or virus DNA or RNA. CSF analysis
CSF investigations may show pleocytosis, increased or decreased glucose, increased protein, antibodies against viruses or against Borrelia burgdorferi, or virus DNA or RNA.
Radiological imaging such as CT, MRI If history and examination suggest the possibility of underlying neurological abnormality, radiological imaging is recommended. MRI is really helpful in identifying brain stem pathology, HRCT is better in the evaluation of the intratemporal portion of the nerve.Contrast enhanced MRI can identify sections of affected nerve in idiopathic facial palsy. Radiological imaging such as CT, MRI
If history and examination suggest the possibility of underlying neurological abnormality, radiological imaging is recommended. MRI is really helpful in identifying brain stem pathology, HRCT is better in the evaluation of the intratemporal portion of the nerve.Contrast enhanced MRI can identify sections of affected nerve in idiopathic facial palsy.

Investigations - Management

Fact Explanation
Neurophysiological studies: electromyography Neurophysiological studies help in evaluation as well predicting the prognosis While several tests exist, the presence of fibrillation potentials in muscles indicates significant axonal degeneration .this test can provide an objective assessment on patient prognosis in long term Neurophysiological studies: electromyography
Neurophysiological studies help in evaluation as well predicting the prognosis While several tests exist, the presence of fibrillation potentials in muscles indicates significant axonal degeneration .this test can provide an objective assessment on patient prognosis in long term
fasting blood sugar or HbA1c Diabetes mellitus causes secondary facial nerve palsy, It has been seen in more than 10 percent of patients with Bell's palsy, When the patient present with additional risk factors (e.g., family history, obesity, older than 30 years).fasting glucose or A1C testing should be performed . fasting blood sugar or HbA1c
Diabetes mellitus causes secondary facial nerve palsy, It has been seen in more than 10 percent of patients with Bell's palsy, When the patient present with additional risk factors (e.g., family history, obesity, older than 30 years).fasting glucose or A1C testing should be performed .

Management - Supportive

Fact Explanation
Patient education education of the patient regarding the condition, cause , treatment and prognosis is essential part in management. Psychological support is mandatory. Patient education
education of the patient regarding the condition, cause , treatment and prognosis is essential part in management. Psychological support is mandatory.
Facial physiotherapy physiotherapy including automassage, relaxation exercises, coordination exercises, or emotional expression exercises, are proven to be beneficial in improvement of facial expression. Facial physiotherapy
physiotherapy including automassage, relaxation exercises, coordination exercises, or emotional expression exercises, are proven to be beneficial in improvement of facial expression.
Eye care Denervation of lacrimal glands causes lack of lubrication and irritation of eye artificial tear drops during the day and lubricating ophthalmic solution in night is recommended to prevent dry eyes and corneal damage Eye care
Denervation of lacrimal glands causes lack of lubrication and irritation of eye artificial tear drops during the day and lubricating ophthalmic solution in night is recommended to prevent dry eyes and corneal damage
Hyperboric oxygen therapy Hyperboric oxygen treatment may improve the duration of recovery and the proportion of persons who make a full recovery,in comparison with corticosteroids; however, the evidence for this is weak. Hyperboric oxygen therapy
Hyperboric oxygen treatment may improve the duration of recovery and the proportion of persons who make a full recovery,in comparison with corticosteroids; however, the evidence for this is weak.
Accupunture beneficence of acupuncture in relation to bell s palsy is controversial , But some studies has revealed that increasing evidence for a beneficial effect of acupuncture as an adjunctive treatment of Bell’s palsy. Accupunture
beneficence of acupuncture in relation to bell s palsy is controversial , But some studies has revealed that increasing evidence for a beneficial effect of acupuncture as an adjunctive treatment of Bell’s palsy.

Management - Specific

Fact Explanation
Oral corticosteroids widely used in the management. Prednisone -starring dose 60mg per day then tapering it over 10 days.but the efficacy on bell s palsy has not been clearly demonstrated despite of wide usage. Oral corticosteroids
widely used in the management. Prednisone -starring dose 60mg per day then tapering it over 10 days.but the efficacy on bell s palsy has not been clearly demonstrated despite of wide usage.
Antivirals 7 day course of acyclovir 400 mg , five times per day or7 day course of valacyclovir 1 g ,three times per day the antiviral drugs acy-clovir (Zovirax) and valacyclovir (Valtrex) have been studied to determine if they have any benefit in treatment because of the possible role of HSV-1 in the etiology of Bell's palsy. Antivirals
7 day course of acyclovir 400 mg , five times per day or7 day course of valacyclovir 1 g ,three times per day the antiviral drugs acy-clovir (Zovirax) and valacyclovir (Valtrex) have been studied to determine if they have any benefit in treatment because of the possible role of HSV-1 in the etiology of Bell's palsy.
Pentoxifyllin There were studies showing that pentoxifylline in combination therapy(particularly with steroids and low molecular dextran) has a beneficial effort on the recovery of bell s palsy Pentoxifyllin
There were studies showing that pentoxifylline in combination therapy(particularly with steroids and low molecular dextran) has a beneficial effort on the recovery of bell s palsy
surgical decompression Pathophysiology of bell s palsy explained as acute inflammation and oedema of facial nerve. surgical decompression is proven to have beneficial effect if it is performed within 2 weeks from the onset surgical decompression
Pathophysiology of bell s palsy explained as acute inflammation and oedema of facial nerve. surgical decompression is proven to have beneficial effect if it is performed within 2 weeks from the onset
Tarsorraphy Denervation of orbicularis oculi causes inability of closure of eyelid which leads to several ocular problems. temporary closure of eyelids(tarsoraphy) is used acute management of bell s palsy Tarsorraphy
Denervation of orbicularis oculi causes inability of closure of eyelid which leads to several ocular problems. temporary closure of eyelids(tarsoraphy) is used acute management of bell s palsy
Surgical nerve grafting. Surgical nerve grafting is a treatment option which used rarely in treatment of bell s palsy. Hypoglossalfacial anastomosis is commonly used in nerve grafting Surgical nerve grafting.
Surgical nerve grafting is a treatment option which used rarely in treatment of bell s palsy. Hypoglossalfacial anastomosis is commonly used in nerve grafting

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  1. ALSUHAIBANI AH. Facial Nerve Palsy: Providing Eye Comfort and Cosmesis Middle East Afr J Ophthalmol [online] 2010, 17(2):142-147 [viewed 12 May 2014] Available from: doi:10.4103/0974-9233.63078
  2. AMINOFF MJ. Bell's palsy and its treatment. Postgrad Med J [online] 1973 Jan, 49(567):46-51 [viewed 12 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2495368
  3. BAUGH RF, BASURA GJ et al.Clinical practice guideline: Bell's palsy.Otolaryngology- Head and Neck Surgery[online] . pubmed .2013 Nov;149(3 Suppl):S1-27.[Viewed on 10 May 2014] Available from: doi: 10.1177/0194599813505967.
  4. BLOM S, EKSTRAND T. Electromyography (EMG) and sialometry in the prognosis of Bell's palsy. A methodological study of early investigated, untreated patients. Acta Otolaryngol [online] 1981 Mar-Apr, 91(3-4):289-95 [viewed 12 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/7257761
  5. EARLL JM, KOLB FO. Facial paralysis occurring with hypothyoidism. A report of two cases. Calif Med [online] 1967 Jan, 106(1):56-58 [viewed 12 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1502625
  6. Facial paralysis in hypertension. Br Med J [online] 1966 Dec 24, 2(5529):1547 [viewed 12 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1944951
  7. GANTZ BJ, RUBINSTEIN JT, GIDLEY P, WOODWORTH GG. Surgical management of Bell's palsy. Laryngoscope [online] 1999 Aug, 109(8):1177-88 [viewed 11 May 2014] Available from: doi:10.1097/00005537-199908000-00001
  8. J. M. K. MURTHI , AMRIT B. SAXENA.Bell's palsy: Treatment guidelines. Annals of Indian academy of neurology[online] . Medknow. July 2011.14(suppl 1). S70-S72.[Viewed on 05 th May 2014] Available From:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3152161/#!po=25.0000
  9. JAIN V, DESHMUKH A, GOLLOMP S. Bilateral Facial Paralysis Case Presentation and Discussion of Differential Diagnosis J Gen Intern Med [online] 2006 Jul, 21(7):C7-C10 [viewed 12 May 2014] Available from: doi:10.1111/j.1525-1497.2006.00466.x
  10. JEFFREY D. TIEMSTRA, NANDINI KHATKHATE . Bell's Palsy: Diagnosis and Management[online] Am Fam Physician. 2007 Oct 1;76(7):997-1002 [Viewed on 05 th May 2014] Available From:http://www.aafp.org/afp/2007/1001/p997.html
  11. JEFFREY D. TIEMSTRA, NANDINI KHATKHATE . Bell's Palsy: Diagnosis and Management[online] Am Fam Physician. 2007 Oct 1;76(7):997-1002 [Viewed on 05 th May 2014] Available From:http://www.aafp.org/afp/2007/1001/p997.html
  12. JEFFREY D. TIEMSTRA, NANDINI KHATKHATE. Bell's Palsy: Diagnosis and Management[online] American Family Physician. 2007 Oct 1. 76(7). 997-1002.[ viewed on 08 May 2014] Available from:http://www.aafp.org/afp/2007/1001/p997.html
  13. JEFFREY D. TIEMSTRA, NANDINI KHATKHATE. Bell's Palsy: Diagnosis and Management[online] American Family Physician. 2007 Oct 1. 76(7). 997-1002.[ viewed on 08 May 2014] Available from:http://www.aafp.org/afp/2007/1001/p997.html
  14. JEFFREY D. TIEMSTRA, NANDINI KHATKHATE. Bell's Palsy: Diagnosis and Management [online]American Family Physician. 2007 Oct 1;76(7):997-1002.[Viewed 06 May 2014]Available from:http://www.aafp.org/afp/2007/1001/p997.html
  15. JEFFREY D. TIEMSTRA, NANDINI KHATKHATE. Bell's Palsy: Diagnosis and Management [online]American Family Physician. 2007 Oct 1;76(7):997-1002.[Viewed 06 May 2014]Available from:http://www.aafp.org/afp/2007/1001/p997.html
  16. JOSEF F. Management of peripheral facial nerve palsy. European Archive of Otorhinolaryngology [online]. PubMed. July 2008.265(7).743-752. [Viewed 08 May 2014] Available from:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2440925/
  17. JOSEF F. Management of peripheral facial nerve palsy. European Archive of Otorhinolaryngology [online]. PubMed. July 2008.265(7).743-752. [Viewed 08 May 2014] Available from:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2440925/
  18. JOSEF F. Management of peripheral facial nerve palsy. European Archive of Otorhinolaryngology [online]. PubMed. July 2008.265(7).743-752. [Viewed 08 May 2014] Available from:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2440925/
  19. JULIAN HOLLAND. JONATHAN BERNSTEIN.Bell Palsy:Clinical Evidence Handbook [online]Am Fam Physician. 2011 Oct 15;84(8):947-948.[Viewed on 05 th May 2014] Available From:http://www.aafp.org/afp/2011/1015/p947.html
  20. JULIAN HOLLAND. JONATHAN BERNSTEIN.Bell Palsy:Clinical Evidence Handbook [online]Am Fam Physician. 2011 Oct 15;84(8):947-948.[Viewed on 05 th May 2014] Available From:http://www.aafp.org/afp/2011/1015/p947.html
  21. KWON HJ, KIM JI, LEE MS, CHOI JY, KANG S, CHUNG JY, KIM YJ, LEE SH, LEE S, NAM D, KIM YS, LEE JD, CHOI DY. Acupuncture for sequelae of Bell's palsy: a randomized controlled trial protocol Trials [online] :71 [viewed 12 May 2014] Available from: doi:10.1186/1745-6215-12-71
  22. LLOYD AV, JEWITT DE, STILL JD. Facial paralysis in children with hypertension. Arch Dis Child [online] 1966 Jun, 41(217):292-294 [viewed 12 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2019561
  23. M RIORDEN. Investigation and treatment of facial paralysis. Archives of disease in childhood [online] . PubMed .April 84(4). 286–288. [ viewed on 08 May 2014] Available from: doi 10.1136/adc.84.4.286
  24. M RIORDEN. Investigation and treatment of facial paralysis. Archives of disease in childhood [online] . PubMed .April 84(4). 286–288. [ viewed on 08 May 2014] Available from: doi: 10.1136/adc.84.4.2862001. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1718736/pdf/v084p00286.pdf
  25. MAY M. Peripheral facial paralysis: diagnosis, prognosis, and treatment. J Natl Med Assoc [online] 1972 Sep, 64(5):424-426 [viewed 12 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2608734
  26. MCFARLIN A, PECKLER B. An unusual presentation of Bell's palsy: A case report and review of literature J Emerg Trauma Shock [online] 2008, 1(1):50-52 [viewed 12 May 2014] Available from: doi:10.4103/0974-2700.40574
  27. MITSUKAWA N, MORIYAMA H et al .Study on distribution of terminal branches of the facial nerve in mimetic muscles (orbicularis oculi muscle and orbicularis oris muscle).Annals of plastic sugery[online]. PubMed .2014 Jan.72(1).71-4.[Viewed 09 May 2014]Availble from: doi: 10.1097/SAP.0b013e318284eca0.
  28. MURAI A, KARIA S,et al.The facial nerve canal in patients with Bell's palsy: an investigation by high-resolution computed tomography with multiplanar reconstruction.European Archive for Otorhinolaryngology{online] PubMed.2013 July .270(7).2035-8 [ viewed on 08 May 2014] Available from. doi: 10.1007/s00405-012-2253-7.
  29. Murthy J .M K ,AMRIT B SUXENA ,Bell's palsy: Treatment guidelines .Annals of indian Academy of neurology[online] Medknow . July 2011.14(suppl1) S70-S72[Viewed on 10 th May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3152161/
  30. RAPOZA PA, HARRISON DA, BUSSA JJ, PRESTOWITZ WF, DORTZBACH RK. Temporary sutured tube-tarsorrhaphy: reversible eyelid closure technique. Ophthalmic Surg [online] 1993 May, 24(5):328-30 [viewed 11 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/8515949
  31. Raquel Ysabel Guzmán LirianoI ,Sandra Lira Bastos de MagalhãesI , et al .Relation of hyperacusis and peripheral facial paralysis - Bell's palsy.Revista Brasileira de Otorrinolaringologia[online] Nov./Dec. 2004: vol.70 no.6 :.[Viewed on 10 May 2014] Available from:http://www.scielo.br/scielo.php?pid=S0034-72992004000600012&script=sci_arttext&tlng=en
  32. SENCHYNA M, WAX MB. Quantitative assessment of tear production: A review of methods and utility in dry eye drug discovery J Ocul Biol Dis Infor [online] 2008 Mar, 1(1):1-6 [viewed 12 May 2014] Available from: doi:10.1007/s12177-008-9006-2
  33. SOCOLOVSKY M, PáEZ MD, MASI GD, MOLINA G, FERNáNDEZ E. Bell's palsy and partial hypoglossal to facial nerve transfer: Case presentation and literature review Surg Neurol Int [online] :46 [viewed 11 May 2014] Available from: doi:10.4103/2152-7806.95391
  34. STEW B, WILLIAMS H. Modern management of facial palsy: a review of current literature Br J Gen Pract [online] 2013 Feb, 63(607):109-110 [viewed 12 May 2014] Available from: doi:10.3399/bjgp13X663262
  35. TEIXEIRA LJ, VALBUZA JS, PRADO GF. Physical therapy for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev [online] 2011 Dec 7:CD006283 [viewed 12 May 2014] Available from: doi:10.1002/14651858.CD006283.pub3