Bell's palsy or idiopathic facial paralysis is a dysfunction of cranial nerve VII (the facial nerve)

that results in inability to control facial muscles on the affected side. Several conditions can
cause a facial paralysis, e.g., brain tumor, stroke, and Lyme disease. However, if no specific
cause can be identified, the condition is known as Bell's palsy. Named after Scottish anatomist
Charles Bell, who first described it, Bell's palsy is the most common acute mononeuropathy
(disease involving only one nerve) and is the most common cause of acute facial nerve paralysis.

Bell's palsy is defined as an idiopathic unilateral facial nerve paralysis, usually self-limiting. The
trademark is rapid onset of partial or complete palsy, usually in a single day. It can occur
bilaterally resulting in total facial paralysis in around 1% of cases. [2]

It is thought that an inflammatory condition leads to swelling of the facial nerve. The nerve
travels through the skull in a narrow bone canal beneath the ear. Nerve swelling and compression
in the narrow bone canal are thought to lead to nerve inhibition, damage or death. No readily
identifiable cause for Bell's palsy has been found.

Corticosteroids have been found to improve outcomes while anti-viral drugs have not. Early
treatment is necessary for steroids to be effective. Most people recover spontaneously and
achieve near-normal to normal functions. Many show signs of improvement as early as 10 days
after the onset, even without treatment.

Often the eye in the affected side cannot be closed. The eye must be protected from drying up, or
the cornea may be permanently damaged resulting in impaired vision. In some cases denture
wearers experience some discomfort.

Treatment of Bell's Palsy

A primary concern in the management of Bell's palsy is eye care. The inability to close one
eye may lead to corneal abrasions and other injuries, especially during sleep. Regardless of
what other therapy is undertaken, dark glasses should be worn during the day, eye drops
used to prevent drying and a bland eye ointment applied before retiring to bed for the night.

An oral steroid such as prednisone is commonly prescribed. The scientific basis for this
treatment is that is helps reduce the inflammation of the nerve and shorten the recovery
period. Several studies suggest that prednisone is effective in shortening the disease course
and improving recovery rates, but other studies show little benefit. An improved rate of
recovery with steroid therapy was especially noticeable in a group of patients with diabetes.

The use of antiviral medications such as acyclovir, often in addition to prednisone, is

somewhat controversial. It is clearly justified when there is evidence of facial palsy caused
by varicella zoster infection (Ramsey Hunt syndrome), but there is less evidence to support
its use in cases of Bell’s palsy, where the evidence for a viral cause is less convincing to
date.

In severe cases, surgery can relieve pressure on the nerve at the narrowest point of the
bony canal and potentially avoid permanent nerve damage, but this procedure remains
controversial. After approximately the first two weeks, permanent nerve damage has
probably already occurred, and surgery is much less likely to be beneficial. Thus, the
optimal time for surgery to be considered is during the second week of the illness, if there is
no sign of improvement. Permanent hearing loss may occur as a complication of the
surgery.

The vast majority of individuals with Bell’s palsy recover completely or have minimal
deficits, even without treatment. The percentage appears to be somewhat higher with
medical and surgical treatment. In the small number of patients who have significant
permanent deficits, reconstructive surgery may sometimes be beneficial.

Causes and Risk Factors of Bell's Palsy

The cause of the nerve irritation associated with Bell’s palsy is unknown. Anecdotally,
exposure to cold is a frequently cited cause – for example, driving with a car window open
in frigid weather, or sleeping with the window open on a chilly night. This association
remains speculative. Some evidence suggests that the cause is inflammation of cranial
nerve VII triggered by a viral infection, perhaps in the herpes family. The risk increases
through the first 30 years of life, remains steady until approximately 70 years, then
increases further. People with diabetes or high blood pressure, as well as pregnant women,
are at slightly greater risk, but most patients are ordinary people with no known
predisposing factors. Some cases have recently been reported after administration of
intranasal influenza vaccine.

Symptoms of Bell's Palsy

The classic presentation of Bell's palsy is weakness on one side of the face. The potential
range of weakness is wide – it may range from difficulty blinking all the way to a complete
paralysis on one side of the face with an inability to close the eye. Onset usually occurs
acutely, but the weakness may worsen for 24 to 48 hours before stabilizing.

The first awareness of the problem may involve drooling after brushing the teeth or when
drinking, an asymmetrical appearance of the mouth noticed in the mirror, an inability to
whistle, or excessive tearing in one eye. A man may say that he was unable to blow out his
cheeks when shaving. Sometimes the onset is subtle and a family member or a work
associate is the first to notice the patient's facial asymmetry.

People with Bell's palsy may describe the sensation of unilateral loss of facial movement as
deadness, loss of feeling, or numbness, although the affected part of the face is neither
asleep nor tingling. Misidentification of the affected part is common. Alteration of taste or
hearing is occasionally a symptom.

It is important to remember that facial paralysis does not always mean an individual has
Bell’s palsy. Other diagnoses should be considered, especially stroke, Lyme disease, and
varicella zoster (Ramsey Hunt syndrome). Less common causes include HIV infection,
sarcoidosis, Sjögren’s syndrome, amyloidosis, and tumors. Only a physician can distinguish
among these possibilities by performing a careful examination. Diagnostic studies such as
Lyme titers and neuroimaging may be indicated depending on the individual case.

Definition of Bell's Palsy

Article updated and reviewed by Peter B. Kang, MD, Assistant in Neurology, Children's Hospital Boston, and Instructor in
Neurology, Harvard Medical School, Boston, MA on April 18, 2005.
Bell's palsy is a facial paralysis caused by an irritation of cranial nerve VII (seven) with no
apparent cause. This excludes facial paralysis associated with known causes such as
infection or stroke. Cranial nerve VII controls most facial muscles, including those needed to
smile, blink, and wrinkle the forehead. The nerve also controls the function of certain
salivary glands and the lacrimal (tear) glands as well as the tiny muscles inside the ear that
dampen loud noises.

Description of Bell's Palsy

Bell's palsy, named after the 19th-century Scottish surgeon Sir Charles Bell, afflicts about
20,000 Americans each year. The nerve becomes inflamed and swollen within a bony tunnel
in the skull that opens just beneath the ear.