Bells Palsy

January 20,2010
 History
- Sir Charles Bell,
Scottish Surgeon
- First described in
early 1800s based
on trauma to facial
nerves
- Definition of Bells
Palsy: Acute
peripheral CN VII
(facial nerve) palsy
of unknown cause
 Anatomy

1) Motor to facial muscles

2) Parasympathetic innervation to lacrimal, submandibular, sublingual salivary glands
3) Afferent fibers for taste on anterior 2/3 tongue
4) Somatic afferents to external auditory canal & pinna
 Epidemiology
of all facial palsys qualify as Bells Palsy

Annual Incidence 10-40/100,000

Lifetime incidence 1:60

Risk is 3xs greater in pregnancy, especially 3 rd

trimester

Increased risk with diabetes

 Cause
Widely accepted cause is HSV-1,
however not proven

HSV mediates inflammatory/immune

response which leads to myelin
sheath degeneration, & edema which
causes compression and further
damage of CN VII
Clinical Features
Sudden onset symptoms,
usually hours w/ maximal
weakness w/in 48 hrs
Unilateral
Eyebrow sagging
Inability to close eye
Loss of nasolabial fold
Decreased tearing
Hyperacusis
Loss of taste to anterior
2/3 tongue
Mouth droop
 Differential Diagnosis
Infection Metabolic
External otitis Otitis media DM
Mastoiditis Hyperthyroidism
Chickenpox Vitamin A deficiency
Herpes zoster (Ramsey Hunt syndrome) Toxic
Encephalitis Poliomyelitis (type I) Iatrogenic
Mumps Idiopathic
Mononucleosis Bell's
Leprosy Melkersson-Rosenthal syndrome
Influenza (recurrent alternating facial palsy,
Coxsackievirus furrowed tongue)
Malaria Amyloidosis
Syphilis Landry-Guillain-Barre syndrome
Tuberculosis Multiple sclerosis
Botulism Myasthenia gravis
Lyme disease Sarcoidosis
Tumor, central or local Birth
Trauma
 Ramsey Hunt Syndrome
AKA Herpes Zoster Oticus: Reactivation of
VZV within geniculate ganglia
Lifetime incidence VZV 10-20%; if live to
be 85, 50%
Risk Factors: Age, Malignancy,
Immunosuppressed
Pathophysiology:
1) Age related immunosenescence
2) Disease associated
immunocompromise
3) Iatrogenic immunosuppression
Clinical Features
Acute Vertigo
Hearing loss
Ipsilateral facial paralysis
Ear Pain
Vesicular rash
Rx: Steroids, acyclovir
 Evaluation & Diagnosis
Bells Palsy is a clinical Proceed with imaging
diagnosis based on (MRI) if
typical presentation
Atypical Presentation
absence of other
explanation or other Slowly progressive over
underlying disease 2-3 weeks
absence of cutaneous If no improvement in
lesions symptoms in 6 wks
otherwise normal neuro
Electrophysiology
exam
Possible Labs to check:
(CMAP) performed if
ESR, RPR, Lyme titer, complete facial
glucose, PCR if vesicular paralysis remains after
lesions 1 week of treatment
 Treatment
Manual closing of eye such as with tape
while sleeping, lubricating eye drops
Steroids 60-80 mg daily x 5 days then
tapered over next 5 days or 1 mg/kg
daily x 7 days
+/-Acyclovir 400 mg 5xs daily x 10
days vs Valacyclovir 1 g BID x 7 days
Surgical Decompression no good
evidence to support
 Prognosis
80% recover within weeks to months

If motor nerve conduction studies

show evidence of denervation after
10 days indicates prolonged recovery
of ~ 3 months & possible incomplete
recovery