Neurological Disorders: Bell's Palsy and Facial Paralysis

• Neurological disorders include Bells Palsy, Trigeminal Neuralgia, Cerebrovascular Event (TIA, CVA), and Concussion

Bell's Palsy Overview

• Bell's palsy causes sudden, temporary weakness in facial muscles, resulting in drooping and a one-sided smile.
• The eye on the affected side resists closing.
• It can occur at any age.
• The exact cause is unknown, but it is believed to be the result of swelling and inflammation of the facial nerve, cranial nerve VII.
• Bell's Palsy is usually temporary, with symptoms improving in a few weeks and complete recovery in 6 months in most cases.
• A few people may have long-term symptoms, and the condition rarely recurs.

Facial Paralysis

• The facial nerve (CN VII) passes through a narrow corridor of bone on its way to the face.
• Facial weakness or paralysis may cause one corner of the mouth to droop, and make it difficult to retain saliva on the side of the mouth affected.
• It can also make it difficult to close the affected eye.
• In 1828, Charles Bell distinguished between the fifth and seventh cranial nerves.
• The seventh cranial nerve is involved mainly in the motor function of the face and the fifth cranial nerve primarily conducts sensation.
• The facial nerve contains parasympathetic fibers to the nose, palate, and lacrimal glands, and has a tortuous course, both centrally and peripherally.
• A 30-mm intraosseous course through the internal auditory canal (along with the eighth cranial nerve) and the internal fallopian canal in the petrous temporal bone is followed by the facial nerve.
• This bony confinement limits amount that the nerve can swell before it becomes compressed.

Bell's Palsy Epidemiology

• The incidence is 20 per 100,000 annually.
• It is common among young and middle adults ages 15-45.
• Men and women are equally affected.
• It is more common in the third trimester of pregnancy or in the first week after giving birth.
• It is more common in those with influenza B or other upper respiratory infections, or diabetes.

Bell's Palsy Etiology

• The exact cause remains unknown.
• It is often related to a viral illness such as Herpes simplex (I and II), Herpes zoster, Epstein-Barr, Cytomegalovirus, Adenovirus, Mumps, Rubella, Influenza B, Coxsackievirus, and Lyme's disease (bacterial).

Clinical Presentation of Bell's Palsy

• Sudden onset of mild weakness to total paralysis on one side of the face.
• Facial droop and difficulty making facial expressions, such as closing one eye or smiling.
• Drooling can happen.
• Postauricular pain around the jaw or in or behind the ear on the affected side.
• Hyperacusis, which is increased sensitivity to sound on the affected side.
• Headache.
• A decrease in taste.
• Changes in the production of tears and saliva.

Bell's Palsy Physical Exam

• Observe for facial asymmetry such as smile, nasolabial folds, and blinking.
• General exam includes otoscopy, palpation of masses near neck and face, and skin exam.
• Motor Function assessment includes raising eyebrows, closing eyes tightly, smiling, puffing out cheeks, pursing lips, and grimacing.
• Sensory function assessment includes sensation of the face and ears, and taste sensation of the anterior 2/3rd of tongue.
• Assess reflexes like the Orbicularis reflex (tap the glabella) for asymmetry in blink pattern, and observe upward movement of eyes during forced eye closure, called Bell Phenomenon.

Bell's Palsy Diagnostics

• No routine labs or imaging are usually recommended with Bell's Palsy.
• Considerations can include Lyme titers, HIV, RPR, and DM screen for at-risk patients.
• MRI of the Brain is considered for patients who have an atypical presentation, recurrent paralysis, additional cranial nerve involvement, paralysis lasting longer than 3 months to rule out other causes (lesions).
• Electrodiagnostic testing considered for patients with complete facial paralysis after 7 days.

Bell's Palsy Differentials

• Lyme Disease cause Spirochete Borrelia burgdorferi with a Distinguishing Feature of an area where Lyme’s is endemic.
• Tumors related to the Brain, metastasis Cholesteatoma, parotid gland, gradual onset, change in mental status, history of cancer and related symptoms.
• Otitis media cause bacterial infection. Distinguishing features include ear pain, fever, and conductive losses.
• Ramsey Hunt Syndrome cause Herpes Zoster Virus (oticus) and pain, vesicular eruption in the ear canal or the oropharynx.
• Sarcoidosis is caused by autoimmune problems and distinguishing factors that are usually bilateral.
• Multiple Sclerosis is caused by demyelination and multiple neurological symptoms affecting multiple regions.
• CVA/TIA is caused by brain-related instances and is unilateral to all extremities.

Bell's Palsy Management

• Steroids offer maximum benefit - Prednisone or Prednisolone 60-80mg for 5 days with taper by 10mg/ day for a total of at least 10 days can be considered.
• Antivirals are used in conjunction with steroids - Acyclovir 400mg PO 5x a day for 5-7 days or Valacyclovir 1000mg 3 x day for 5-7 days can be considered.
• NSAID's for pain where appropriate.
• Eye protection is important - use an eye patch at night, lubricant eye drops every 2 hours, and protective glasses.
• Physical therapy and facial massage using Warm moist compresses is helpful to restore muscle strength.
• Acupuncture can also be considered.

Bell's Palsy Follow Up/Referral

• Recommend 3-5 days if medications are prescribed or 2-4 weeks until resolved.
• Ophthalmology referral for eye complications example, corneal abrasion.
• Neurology referral for CNS (central nervous system) involvement or if suspected.
• Neurosurgery referral for decompressive surgery for those with 90% nerve compression.
• Otolaryngology referral for Botox injections if not resolved in 3 months.
• 80% of patients recover completely.
• Long-term nerve damage can be found in 15% of patients.
• 5% of patients will have severe sequelae, this may include - Facial asymmetry, Vision loss, Hearing loss, and/or Tinnitus.