Bells Palsy
Acute unilateral facial nerve palsy.
Patients with Bell's palsy can be managed in the community. They can be assessed
next day in Singleto ENT Clinic after discussion with ENT
Differential diagnosis includes stroke and Ramsay-Hunt syndrome (see below).
If diagnostic doubt remains the patient can be referred to the next TIA clinic for a
consultant opinion.
Differential diagnosis
"It is important to identify whether the patient has an upper motor neurone (UMN) or
lower motor neurone (LMN) lesion to assist in identifying cause.
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In a LMN lesion [e.g. Bell's palsy] the patient can't wrinkle their forehead - the
final common pathway to the muscles is destroyed. Lesion must be either in
the pons, or outside the brainstem (posterior fossa, bony canal, middle ear or
outside skull).
In an UMN lesion [e.g. stroke], the upper facial muscles are partially spared
because of alternative pathways in the brainstem i.e. the patient can wrinkle
their forehead (unless bilateral lesion) and the sagging of the face seen with
lower motor neurone palsies is not as prominent. There appear to be different
pathways for voluntary and emotional movement.
CVA's usually weaken voluntary movement often sparing involuntary movements
(e.g. spontaneous smiling). The much rarer selective loss of emotional movement is
called mimic paralysis and is usually due to a frontal or thalamic lesion."
Give patient information from PatientUK
Ramsay Hunt syndrome. Lower motor neuron facial palsy may be due to Varicella
zoster virus (VZV) reactivation. The following additional symptoms may suggest
VZV:
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deafness
dizziness
vertigo
vesicles, often in pharynx and ear, but sometimes there is no rash
Consider treatment with high dose antivirals e.g. acyclovir (first line). Treatment
must be started within 48 hours of onset.
Treatment of Bell's palsy
Treatment with high dose oral steroids does improve the complete facial recovery rate
if given within 3 days of onset. . Adult Bell’s palsy : Start Prednisolone 1mg / kg
body weight per day (a maximum of 60mg) for a week if no contraindications &
Aciclovir 400mg 5 times a day for a week if seen within 3 days of onset.
Consider artificial tears and taping closed eyelid to protect cornea.