Facial Paralysis & Bell's Palsy

Differentiate supranuclear facial palsy from peripheral (nuclear) facial palsy. Supranuclear palsy involves predominantly the lower part of the face. Emotional responses may be intact (e.g., the patient may not be able to show you his teeth but will smile in response to a joke). Peripheral, or nuclear facial, palsy affects all ipsilateral muscles of facial expression, resulting in paralysis of the entire ipsilateral side. The mouth is pulled at an angle to the normal side and may droop on the affected side, facial creases are effaced, and the eyelid may not close.

Differential Diagnosis

• Bell's palsy (idiopathic facial palsy of lower motor neuron type)
  –Most common cause of facial nerve paralysis

• Acoustic neuroma
  –May compress the facial nerve
• Pontine lesions
  –Secondary to infarcts, demyelinating processes, or tumors
  –Signs of brainstem involvement may be associated
• Facial diplegia or bilateral facial palsy
  –Guillain-Barré syndrome (associated with ascending areflexic motor paralysis)
  –Heerfordt's syndrome (a form of sarcoidosis; also known as uveoparotid fever)

• Melkersson-Rosenthal syndrome
  –Recurrent facial palsy, labial edema, and tongue plication

Workup and Diagnosis

• History and physical examination, with complete ENT and neurologic exams
  –Associated neurologic deficits may occur (e.g., weakness of the arm or leg, aphasia) due to involvement of surrounding brain areas in a vascular event
  –Depending on the site of interruption, the patient may have hyperacusis, a loss of taste over the anterior 2/3 of tongue, deafness, tinnitus, dizziness, or associated brainstem signs
  –Bell's palsy is a clinical diagnosis with testing reserved for atypical presentations or slowly resolving cases; make sure there are no herpetic lesions in the pharynx or external auditory canal; also pay special attention to assessing the eighth cranial nerve, as it courses very close to the facial nerve

• Initial labs may include CBC, glucose, ESR, and Lyme titer
• Head MRI
• In cases of supranuclear palsy, a workup for CVA, demyelinating processes, and/or tumors may be indicated; include CT, MRI, and CSF studies

Treatment

• Bell's palsy
  –IV acyclovir and corticosteroids may lead to better recovery and less neuronal degeneration
  –Tape eye and use eye shade to protect the eye during sleep
  –Massage of weakened muscles
  –Electrical stimulation of paralyzed muscles in cases with delayed recovery

• In other cases, treat the inciting causes (e.g., control of blood pressure and hyperlipidemia in patients with CVA, antibiotics for patients with Lyme disease, antivirals in Ramsay Hunt's syndrome, steroids for sarcoidosis)
• Consider neurologic referral

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

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Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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