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Stroke vs. Bell's Palsy

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Interpretation

Bell's Palsy vs Stroke

Treatment

Related Content

References

Editors & Reviewers

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Interpretation
If you have a patient come in complaining of new or acute onset of unilateral facial paralysis
without any other sensory or motor deficits (i.e., no upper or lower extremity weakness) the next
thing you need to do is determine which parts of the face are affected. Have the patient attempt
to raise both eyebrows as if surprised. Then have the patient smile.
If they cannot raise their eyebrows and cannot move the lower portion of their face they have
Bell's palsy and should be given steroids +/- antivirals.
If the lower portion of the face is paralyzed but the eyebrows rise symmetrically, then you
have to be concerned for a stroke and should get imaging and further consideration of
treatment (depending on time of presentation and cause).

Bell's Palsy vs. Stroke

Bell's palsy (also called idiopathic facial paralysis) is the most common cause of unilateral facial
paralysis. It has the following features:
Acute onset of unilateral upper AND lower facial paralysis
Flattening of the forehead and inability to raise eyebrows on affected side

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On smiling the face lateralizes to the opposite (normal side)

Hyperacusis
Changes in taste
Impaired eyelid closure
The above symptoms are thought to occur as a result of the injury, swelling, and/or ischemia of
the facial nerve (CN VII) as a result of compression as it passes through the facial canal. While
the exact cause is unknown, it appears that viral infection (herpes virus) is associated.
Bell's Palsy is a peripheral nerve effect whereas a ischemic stroke is a central process. As shown
in the diagram, the forehead receives motor innervation from both hemispheres of the cerebral
cortex. A stroke that compromised motor innervation of the face would therefore only result in
paralysis of the lower half of the face - the forehead still receiving innervation from the
unaffected hemisphere. A peripheral lesion, such as Bell's Palsy, interrupts the innervation after
the motor commands from both hemispheres have joined, so that the forehead is paralyzed.

Treatment of Bell's Palsy

Therefore, the location of the lesion is important in differentiating the two clinical scenarios
whose treatments are drastically different. Patients with Bell's palsy should be given steroids
within 72 hours of onset +/- antivirals, and +/- eye lubricant to prevent corneal abrasions or
ulcers. Dosing regimens include:
Prednisone 1 mg/kg in 2 divided doses by mouth daily x 5 days, then 5 mg by mouth twice a
day for another 5 days for a total of 10 days of steroids.
Valacyclovir 500 mg by mouth twice a day x 5 days
Alternative option (due to compliance): Acyclovir 800 mg by mouth 5 times per day x
7-10 days
Erythromycin ophthalmic ointment 1/2 inch into the affected eye 2 - 4 times per day

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References
1. Baugh RF et al. Clinical Practice Guidelines: Bell's Palsy Executive Summary. Otolaryngol
Head Neck Surg 2013;149(5):656-63.
2. Gronseth GS et al. Evidenced-based guidelines update: steroids and antivirals for Bell palsy:
report of the Guideline Development Subcommittee of the American Academy of Neurology.
Neurology 2012;79(22):2209-13.
3. Sullivan FM et al. Early treatment with prednisolone or acyclovir in Bell's palsy. N Engl J
Med 2007;357:1598.

Editors & Reviewers

Editors:
Anthony J. Busti, MD, PharmD, FNLA, FAHA
Dylan Kellogg, MD
Last Updated: July 2015

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