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Bell’s Palsy

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

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Bell’s Palsy

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  1. Bell’s Palsy January 20,2010

  2. History • Sir Charles Bell, Scottish Surgeon • First described in early 1800s based on trauma to facial nerves • Definition of Bell’s Palsy: Acute peripheral CN VII (facial nerve) palsy of unknown cause

  3. Anatomy • Motor to facial muscles • Parasympathetic innervation to lacrimal, submandibular, sublingual salivary glands • Afferent fibers for taste on anterior 2/3 tongue • Somatic afferents to external auditory canal & pinna

  4. Epidemiology • ½ of all facial palsy’s qualify as “Bell’s Palsy” • Annual Incidence 10-40/100,000 • Lifetime incidence 1:60 • Risk is 3xs greater in pregnancy, especially 3rd trimester • Increased risk with diabetes

  5. 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

  6. 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

  7. Differential Diagnosis • Infection • External otitisOtitis media • Mastoiditis • Chickenpox • Herpes zoster (Ramsey Hunt syndrome) • Encephalitis Poliomyelitis (type I) • Mumps • Mononucleosis • Leprosy • Influenza • Coxsackievirus • Malaria • Syphilis • Tuberculosis • Botulism • Lyme disease • Tumor, central or local • Metabolic • DM • Hyperthyroidism • Vitamin A deficiency • Toxic • Iatrogenic • Idiopathic • Bell's • Melkersson-Rosenthal syndrome (recurrent alternating facial palsy, furrowed tongue) • Amyloidosis • Landry-Guillain-Barre syndrome • Multiple sclerosis • Myasthenia gravis • Sarcoidosis • Birth • Trauma

  8. 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

  9. Evaluation & Diagnosis • Bell’s Palsy is a clinical diagnosis based on • typical presentation • absence of other explanation or other underlying disease • absence of cutaneous lesions • otherwise normal neuro exam • Possible Labs to check: ESR, RPR, Lyme titer, glucose, PCR if vesicular lesions • Proceed with imaging (MRI) if • Atypical Presentation • Slowly progressive over 2-3 weeks • If no improvement in symptoms in 6 wks • Electrophysiology (CMAP) performed if complete facial paralysis remains after 1 week of treatment

  10. 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 vsValacyclovir 1 g BID x 7 days • Surgical Decompression – no good evidence to support

  11. 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

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