Bell's palsy
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Bell’s palsy
Jo Piercy
This is part of
A 32 year old man presents to you with sudden onset Useful reading
a series of
of weakness on the left side of his face. He also says that occasional
he is unable to close his left eye. He is otherwise well Bandolier. Bell’s palsy systematic reviews.
articles on
and last saw a doctor five years ago. He is anxious and problems in
primary care

What issues you should cover
Holland NJ, Weiner GM. Recent developments inBell’s palsy. BMJ 2004;329:553-7 Associated symptoms—Patients with Bell’s palsy com- monly feel pain in or behind the ear. Numbness can Salinas R. Bell’s palsy. In: Clinical evidence concise.
occur on the affected side of the face. Loss of taste on Issue 11. London: BMJ Publishing, 2004: 311 the ipsilateral anterior two thirds of the tongue is com- mon. Ask about associated hyperacusis and any presence of rash that may indicate herpes zoster.
Aetiology—Ask about recent viral infection and recent demyelination. Although it is rare, always bear in mind immunisation. The causes of Bell’s palsy are unknown, the possibility of a seventh nerve palsy caused by a but the possibilities include viral infection, heredity, autoimmune or vascular ischaemia, of which the most Treatment
Incidence—Bell’s palsy is commonest in the age group x Two recent systematic reviews concluded that Bell’s 10 to 40 years. Each year about 20 cases per 100 000 palsy can be effectively treated with corticosteroids in the first seven days after onset, with a further 17% of patients having a good outcome in addition to the 80% What you should do
that spontaneously improve. Recovery rates in patients Examination
treated within 72 hours were enhanced with the addi-tion of aciclovir. It is thought that prednisolone acts by x You will need to differentiate between an upper and lower motor neurone lesion of the facial nerve. A lower reducing oedema of the facial nerve. Antivirals inhibit motor neurone lesion occurs with Bell’s palsy, whereas viral replication. So, recent evidence supports the use an upper motor neurone lesion is associated with a of oral prednisolone and aciclovir in patients with cerebrovascular accident. A lower motor neurone moderate to severe palsy, ideally within 72 hours but lesion causes weakness of all the muscles of facial up to seven days from onset of symptoms. Pred- expression. The angle of the mouth falls. Weakness of nisolone should be prescribed at a dosage of 1 mg/kg/ frontalis occurs, and eye closure is weak. With an upper day (maximum 80 mg daily) for the first week, with the motor neurone lesion frontalis is spared, normal dosage tapering off over the second week. Aciclovir is furrowing of the brow is preserved, and eye closure and given at a dosage of 800 mg five times a day for five x Check that no other cranial nerves are involved.
x As blinking is affected, and his eye may not close, Bell’s palsy is seventh nerve palsy in isolation.
consider an eye pad or taping of the lid so that he can Look also for a painful rash over the ear, which sleep. His cornea will be dry, so prescribe artificial indicates Ramsay Hunt syndrome caused by herpes x Reassure him. Patients are often highly anxious and x Look for pointers to a more serious underlying will need to be firmly reassured that this is not a cause that might require urgent referral of the patient: cerebrovascular accident. Tell him that most patients bilateral Bell’s palsy; recurrent Bell’s palsy; association get better but that a minority won’t.
with a rash elsewhere or with feeling generally unwell(which may indicate sarcoid or Lyme disease); or aprevious episode that could have been the effect of Follow up
x Two thirds of patients recover spontaneously, and
85% report some improvement in the first three weeks.
Information websites for patients
In the other 15% of patients some improvement occursby 3-6 months. Patients need follow up for assessment Bell’s Palsy Information Site ( This site has information on causes, symptoms, treatment, and rehabilitation. It also has a good “frequently asked x Referral to an ear, nose, and throat specialist is advisable for all cases after treatment is begun. Patients Bell’s Palsy Association ( This is with incomplete recovery of facial nerve function may a UK based information site for patients.
ultimately need to be referred to an ophthalmologistfor tarsorrhaphy.
BMJ VOLUME 330 11 JUNE 2005


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