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 3rd

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 Toxic
syndrome) Iatrogenic
Encephalitis Poliomyelitis (type I) Idiopathic
Mumps Bell's
Mononucleosis Melkersson-Rosenthal syndrome
Leprosy (recurrent alternating facial palsy,
Influenza furrowed tongue)
Coxsackievirus Amyloidosis
Malaria Landry-Guillain-Barre syndrome
Syphilis Multiple sclerosis
Tuberculosis Myasthenia gravis
Botulism Sarcoidosis
Lyme disease Birth
Tumor, central or local 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 Slowly progressive over 2-3
explanation or other weeks
underlying disease If no improvement in
absence of cutaneous symptoms in 6 wks
lesions Electrophysiology (CMAP)
otherwise normal neuro performed if complete
exam
facial paralysis remains
Possible Labs to check: after 1 week of treatment
ESR, RPR, Lyme titer,
glucose, PCR if vesicular
lesions
 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