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Updated: Mar 22 2020

Bell Palsy

  • Snapshot
    • A 33-year-old man presents to the emergency department for slurred speech. His symptoms began a few hours prior to presentation and it has progressively worsened. He reports to having difficulty with closing his right eye and being sensitive to sound in the right ear. Physical examination is notable for loss of the nasolabial fold on the right and an inability to close the eye. There are vesicles found by the external acoustic meatus. Sensation is intact throughout the face. He is started on prednisone.
  • Introduction
    • Clinical definition
      • a neurologic deficit secondary to weakness of the facial nerve
  • Epidemiology
    • Incidence
      • 11-40 per 100,000 population
    • Demographic
      • 15-45 years of age
  • Etiology
    • Idiopathic
    • Herpes simplex virus
      • common in most cases
    • Varicella-zoster virus
    • Lyme disease
    • Sarcoidosis
    • Malignancy
    • Diabetes mellitus
  • Pathogenesis
    • Facial nerve palsy may result from inflammatory or infectious insults to the facial nerve
  • Anatomy
    • The facial nerve is a mixed nerve that arises from the pontomedullary junction and contains
      • motor fiber input to the
        • facial muscles
      • parasympathetic fibers to the
        • lacrimal glands
        • submandibular glands
        • sublingual salivary glands
      • afferent fibers from the
        • taste receptors of the anterior two-thirds of the tongue
        • external auditory canal and pinna
  • Presentation
    • Symptoms and physical exam
      • unilateral facial weakness
        • eyebrow sagging
        • inability to close the eye
        • an absence of the nasolabial fold
        • corner of the mouth droops
      • decreased tearing
      • hyperacusis
      • loss of taste sensation of the anterior two-thirds of the tongue
    • Peripheral (lower motor neuron) vs central (upper motor neuron) lesion
      • a lower motor neuron lesion
        • involves the forehead
      • an upper motor neuron lesion
        • spares the forehead
  • Studies
    • Diagnostic criteria
      • clinical diagnosis
  • Differential
    • Stroke
      • differentiating factors
        • infarction noted on MRI brain without contrast
    • Multiple sclerosis
      • differentiating factor
        • MRI brain demonstrating demyelinating lesions
    • Myasthenia gravis
      • differentiating factor
        • presence of acetylcholine receptor (AChR) or muscle-specific kinase (MuSK) antibodies in the serum
  • Treatment
    • Supportive
      • eye ointment
        • indication
          • to lubricate the eye due to the patient's inability to close the eye
    • Medical
      • glucocorticoids
        • indication
          • oral glucocorticoids are the mainstay of pharmacologic treatment in patients with acute idiopathic Bell palsy
  • Complications
    • Ocular manifestations
      • corneal drying and abrasion
  • Prognosis
    • Most patients recover
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