Neurology Book

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Bell's Palsy

Aka: Bell's Palsy, Facial Nerve Paralysis, Facial Nerve Palsy
  1. See Also
    1. Facial Nerve Injury from Birth Trauma
  2. Definition
    1. Idiopathic, acute Facial Nerve Paralysis
  3. History
    1. Named for Sir Charles Bell (1774-1842) who first described the syndrome
  4. Pathophysiology
    1. Facial Nerve inflammation at Geniculate Ganglion (risk of ischemia, demyelination)
  5. Epidemiology
    1. Incidence: 15-30 per 100,000 per year
    2. No gender predominance
    3. Incidence peaks at age 40 years
    4. More common in Diabetes Mellitus (comorbid in 10% of cases)
  6. History: Red Flags suggestive of other Facial Nerve Paralysis Cause
    1. Gradual onset over >2 weeks
      1. Suggests mass lesion
    2. Forehead not involved
      1. Suggests central nervous system cause (supranuclear lesion)
    3. Bilateral involvement
      1. Suggests autoimmune Polyneuropathy
    4. Recent new medications (e.g. Influenza Vaccine)
    5. Recent Tick bite
      1. Consider Lyme Disease
    6. Fever
      1. Consider infectious cause such as Otitis Media
    7. Rash
      1. Vesicular rash (Herpes Zoster)
      2. Erythema Migrans (Lyme Disease)
  7. Exam
    1. Head and neck
      1. Ear canal
      2. Tympanic Membrane
      3. Mouth and pharynx
      4. Parotid Gland
    2. Neurologic Exam
      1. Cranial Nerve Exam
        1. Test Cranial Nerve 7 bilaterally on lower face and forehead
      2. Extremity Motor Exam and Sensory Exam
    3. Skin
  8. Symptoms
    1. Idiopathic Facial Nerve Paralysis
      1. Hypoesthesia or dysesthesia (80%)
        1. Glossopharyngeal Nerve dysfunction
        2. Trigeminal Nerve dysfunction
      2. Facial or retroauricular pain (60%)
      3. Dysgeusia (57%)
      4. Hyperacusis (30%)
      5. Vagal nerve motor weakness (20%)
      6. Decreased Lacrimation (17%)
      7. Trigeminal Nerve motor weakness (3%)
    2. References
      1. Adour (1982) N Engl J Med 307: 348-51
  9. Signs: General
    1. Loss of facial creases and nasolabial fold
    2. Corner of mouth droops
    3. No furrow over forehead (if upper motor neuron lesion)
    4. No closure of Eyelid
    5. Lower Eyelid sag
    6. Decreased tear production
    7. Preserved facial sensation
  10. Signs: Facial Nerve Grading (House-Brackman)
    1. Grade 1: Normal Facial Nerve Function
    2. Grade 2: Mild Facial Nerve Dysfunction
      1. Gross
        1. Slight weakness on close examination
        2. Synkinesis slight
      2. Rest: Normal symmetry and tone
      3. Motor Exam
        1. Forehead: Moderate to good function
        2. Eyes: Complete closure with minimum effort
        3. Mouth: Slight asymmetry
    3. Grade 3: Moderate Facial Nerve Dysfunction
      1. Gross:
        1. Obvious difference between sides (not disfiguring)
        2. Synkinesis noticeable
      2. Rest: Normal symmetry and tone
      3. Motor Exam
        1. Forehead: slight to Moderate movement
        2. Eyes: Complete closure with effort
        3. Mouth: Slightly weak with maximal effort
    4. Grade 4: Moderately Severe Facial Nerve Dysfunction
      1. Gross
        1. Obvious weakness
        2. Disfiguring asymmetry
      2. Rest: Normal symmetry and tone
      3. Motor Exam
        1. Forehead: No motor function
        2. Eyes: Incomplete closure
        3. Mouth: Asymmetric with maximal effort
    5. Grade 5: Severe Facial Nerve Dysfunction
      1. Gross: Barely perceptible motion
      2. Rest: Asymmetry
      3. Motor Exam
        1. Forehead: No motor function
        2. Eyes: Incomplete closure
        3. Mouth: Slight movement
    6. Grade 6: Total Facial Nerve Paralysis
    7. References
      1. House (1985) Otolaryngol Head Neck Surg 93:146-7
  11. Differential Diagnosis
    1. See Facial Nerve Paralysis Causes
  12. Labs
    1. Serum Glucose
    2. Lyme Antibody titer
  13. Imaging: Indicated for supected central cause (see Red Flags above)
    1. MRI Head
  14. Management: Loss of blink reflex
    1. Rewetting the eye
      1. Frequent use of preservative-free artificial tears (every 15 to 30 minutes)
      2. Refresh PM ointment six times daily
    2. Protective glasses with side pieces
      1. Use in outdoors, drafty, dusty areas
      2. Alternatively can use eye shield or cup
    3. Avoid grinding, sanding, or sawing
    4. At night:
      1. Apply bland ointment (Refresh PM, Lacri-Lube)
      2. Tape eye shut
  15. Management: Improved prognosis of Facial Nerve Paralysis
    1. General
      1. Start steroid and antiviral agents within 72 hours
    2. High dose Corticosteroids: Prednisone
      1. Adult: 60 mg orally daily for 5 days and then 40 mg orally for 5 days
      2. Child: 2 mg/kg/day (up to adult dosing) for 7-10 days
    3. Antiviral agents
      1. Mechanism
        1. Based on reactivated HSV hypothesis
      2. Agents
        1. Acyclovir
          1. Adult: 400 mg five times per day for 7 days
          2. Child (>2 years): 80 mg/kg daily (max: 3200 mg/day) divided every 6 hours for 5 days
        2. Valacyclovir
          1. Age >12 years: 1 gram orally three times daily for 7 days
      3. References
        1. Adour (1996) Ann Otol Rhinol Laryngol 105:371-8
        2. Hato (2007) Otol Neurotol 28: 408-13
        3. Hato (2003) Otol Neurotol 24: 948-51
  16. Management: Associated Conditions
    1. Otitis Media or Mastoiditis Complications
      1. IV antibiotics
      2. Otolaryngology consultation for possible wide incision of Tympanic Membrane
    2. Herpes Zoster Oticus
      1. See Herpes Zoster for antiviral agents
      2. High dose Corticosteroids (1 mg/kg/day)
        1. Avoid in Diabetes Mellitus, peptic ulcer, Glaucoma
  17. Management: Referral Indications
    1. Otitis Media complications
    2. Mastoiditis complications
    3. Signs of secondary cause
      1. Intracranial lesion or nerve impingement
  18. Prognosis: Factors associated with poor prognosis
    1. Worse Prognosis with time needed for recovery
      1. No recovery by 3 weeks suggests worse prognosis
    2. Hyperacusis
    3. Diabetes Mellitus
    4. Hypertension
    5. Pregnancy
    6. Facial Nerve with severe degeneration by EMG
    7. Decreased tearing
    8. Age over 60 years
    9. Ramsay Hunt Syndrome (Herpes ZosterVirus)
    10. Severe pain
      1. Aural pain
      2. Anterior facial pain
      3. Radicular pain
  19. Complications
    1. Corneal Ulceration
    2. Permanent Eyelid weakness
    3. Permanent facial asymmetry
  20. Prognosis: Recovery
    1. Full recovery in 75% of cases
    2. Minimal residual deficit in 10%
    3. Moderate to severe deficit in 15%
      1. Facial weakness
      2. Contracture or spasm
  21. Course
    1. Maximal weakness at 3-7 days after onset
    2. Most cases improve within 3 weeks even without treatment
    3. Additional improvement may require up to 6 months
      1. Required for nerve regeneration
    4. Recurrence in 8% of cases
  22. References
    1. Zalvan (1999) Consultant 39(1):39-48
    2. Gilden (2004) N Engl J Med 351:1323-31
    3. Holland (2004) BMJ 329:553-7
    4. Tiemstra (2007) Am Fam Physician 76:997-1002

Facial paralysis (C0015469)

Definition (NCI) Partial or complete paralysis of the facial muscles of one side of a person's face. It is caused by damage to the seventh cranial nerve. It is usually temporary but it may recur.
Definition (MSH) Severe or complete loss of facial muscle motor function. This condition may result from central or peripheral lesions. Damage to CNS motor pathways from the cerebral cortex to the facial nuclei in the pons leads to facial weakness that generally spares the forehead muscles. FACIAL NERVE DISEASES generally results in generalized hemifacial weakness. NEUROMUSCULAR JUNCTION DISEASES and MUSCULAR DISEASES may also cause facial paralysis or paresis.
Definition (CSP) severe or complete loss of facial muscle motor function; this condition may result from central or peripheral lesions; damage to CNS motor pathways from the cerebral cortex to the facial nuclei in the pons leads to facial weakness that generally spares the forehead muscles; facial nerve diseases generally results in generalized hemifacial weakness; neuromuscular junction diseases and muscular diseases may also cause facial paralysis.
Concepts Disease or Syndrome (T047)
MSH D005158
ICD10 G51.0
SnomedCT 90039006, 280816001, 46382007, 155070005, 267703001, 79359001
English Facial nerve palsy, Facial Paralysis, Paralyses, Facial, FACIAL PARALYSIS, PARALYSIS FACIAL, Paralysis, Facial, facial paralysis, Facial nerve paralysis, NOS, Seventh nerve palsy, VII nerve palsy, Facial nerve palsy (cranial nerve VII), Facial paralysis, Facial Palsies, Facial Palsy, Palsies, Facial, Palsy, Facial, FACIAL NERVE PARALYSIS, Bell's Palsy, NERVE PARALYSIS, FACIAL, PARALYSIS OF FACIAL NERVE, Facial Paralysis [Disease/Finding], Paralysis facial, Palsy;facial, facial paralyses, Facial palsy, Seventh nerve paralysis, Facial nerve paralysis, Facial palsy (disorder), facial; paralysis, paralysis; facial nerve, paralysis; facial, Facial Nerve Paralysis, facial palsy, VII th nerve palsy, Palsy;VII nerve
French PARALYSIE FACIALE, Paralysie faciale
Portuguese PARALISIA FACIAL, Paralisia facial, Paralisia Facial, Paresia Facial
Spanish PARALISIS FACIAL, Facial palsy, Parálisis facial, parálisis del nervio facial, parálisis del séptimo par craneal, parálisis facial (trastorno), parálisis facial, Parálisis Facial, Paralisis Facial
Swedish Ansiktsförlamning
Czech faciální paralýza, Obrna lícního nervu
Finnish Kasvohermohalvaus
Russian LITSEVOI PARALICH, MOBIUSA SINDROM, GEMIFATSIAL'NYI PARALICH, LITSEVOGO NERVA PARALICH, ГЕМИФАЦИАЛЬНЫЙ ПАРАЛИЧ, ЛИЦЕВОГО НЕРВА ПАРАЛИЧ, ЛИЦЕВОЙ ПАРАЛИЧ, МОБИУСА СИНДРОМ
German FACIALISLAEHMUNG, Fazialislaehmung, Gesichtslaehmung, Laehmung des Gesichts, Faziale Lähmung, Gesichtslähmung
Japanese 顔面筋麻痺, 顔面神経麻痺, ｶﾞﾝﾒﾝﾏﾋ, ｶﾞﾝﾒﾝｼﾝｹｲﾏﾋ, 顔面神経麻痺-末梢性, 顔面麻痺, 顔面運動麻痺, 末梢性顔面神経麻痺
Croatian PARALIZA FACIJALISA
Dutch facialis verlamming, gelaatsparalyse, paralyse faciaal, facialis; paralyse, paralyse; facialis, paralyse; nervus facialis, Facialisparalyse, Facialisparese, Paralyse, facialis-
Polish Porażenie nerwu twarzowego
Hungarian Facialis bénulás, Facialis paralysis
Italian Paralisi facciale
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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