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Bell's palsy (Epidemiology (Commonest cause of facial palsy, Onset 15…
Bell's palsy
Epidemiology
Commonest cause of facial palsy
Onset 15-60y
M=F
Clinical
presentation
Facial paralysis
Acute onset, unilateral
Impaired mouth closure: sag, drooling, speech, taste
Impaired eye closure: watering, dry eye, ectropion, conjunctivitis
Impaired forehead movement: unable to move brow
Reduced taste
Ageusia
Hyperacusis
If stapedius palsy
Diagnosis
Examination
ENT
Usually nil, may have reduced hearing
Neuro (CN)
Ipsilateral facial drooping, affecting mouth eyes and forehead
No forehead sparing
Bell's phenomenon (eyeball moves upward, see white sclera)
Investigations
Bedside
Obs (nil)
ECG (nil)
Bloods
FBC (infection), CRP/ESR, U+E, LFTs,
ACE (sarcoidosis), Lyme serology,
glucose (DM)
Imaging
CT/MRI head (SOL, stroke)
History
FH
Stroke, H+N tumours
DH
Meds, allergies
PMH
Known medical conditions, surgeries
PC/HPC
Sudden onset facial paralysis,
absence of UMN symptoms
SH
Occupation, living arrangements,
smoking, alcohol
Management
Conservative
Information, advice, support
Eye protection (tape, dark glasses)
Facial exercises
Referral if recurrent, bilateral, diagnostic uncertainty,
or no improvement after 1 month
Medical
Steroids
Indication: ,72h onset
E.g. prednisolone PO
MOA: reduces inflammation and
axonal damage to CN VII
Ocular lubrication
Indication: unable to close eye
E.g. artificial tears (hypromellose)
Botox
Indication: chronic facial asymmetry
Surgical
Lid loading
Indication: long term failed eye closure
MOA: insert weight e.g. gold into eyelid
Plastic surgery
Indication: no recovery >1y
MOA: aids lid closure and facial droop
Lid tasorrhaphy
Indication: ectropion
MOA: partial lid-lid suturing
Prognosis
Most (80%) show resolution
or improvement <3m
15% have slower improvement
5% have permenant weakness
Risk factors
DM
Pregnancy
Differentials
Unilateral
Vascular: stroke
Infection: otitis media, Ramsay Hunt
Trauma: skull base trauma
Autoimmune: MS
Metabolic: DM
Neoplastic: parotid tumor, CNS tumour, acoustic neuroma, meningoma
Bilateral
Infection: GBS, Lyme
Autoimmune: neurosarcoidosis, MS
Metabolic: DM
Complications
Corneal ulcer
Damage to unclosed eye
Psychological
Anxiety, depression
Definition
Neurological disorder of
facial nerve paralysis of
idiopathic cause
Pathophysiology
Mechanism
Unclear cause
Possible HSV-1 reactivation and inflammation
Inflammatory oedema and entrapment of facial nerve in the narrow bony facial canal
Complete unilateral palsy by 24-72h