Bell’s Palsy

Most cases caused by reactivation of Herpes Simplex or Varicella-Zoster Viruses
  • Most common cause of 7th Cranial Nerve Palsy
  • Make Dx by R/O other possibilities

How to R/O Other Causes of CN7 Palsy

1.  No Sx like fever, severe HA, confusion, other Neuro deficits
  • Worry about CNS infection; maybe Primary HIV (see below)
2.  Check the Ear:
  • Palpate canal entrance for masses
  • Percuss mastoid for tender Mastoiditis
  • Otoscopy for Otitis
  • Vesicles in canal or on ext. ear = Zoster (~ “Bell’s)
3.  r/o Stroke
  • Weak forehead & eyebrow muscles = Bell’s
  • Normal strength of forehead & eyebrow = Stroke
  • No other Cranial Nerve deficits in Bell’s (if also vertigo, it’s due to Zoster)
4.  r/o Primary HIV (aseptic meningitis syndrome)
  • Occurs 1-4 weeks after infection
  • Usually H/A & fever (often 2-3 wks before facial palsy)
  • Often bilateral CN7 Palsy
  • Risk Factors: Sexual & Needle-Sharing
  • Dx:  HIV RNA by PCR (viral load)
     — HIV Antibody test is Neg (window period)
     — DON’T order viral load on all Bell’s pts
  • Only if high index suspicion
 5.  Suspect Lyme Disease (“early disseminated” stage) if:
  • exposed in endemic area (mid-May to late-July)
  • Symptom onset mid-June to Dec.
If above risk: order Lyme serology IgM, then Tx if pos.
  • Rx Prednisone for simple Bell’s while waiting (see below)
Dx Lyme empirically if:
  • Bilateral Palsy (Tx Bell’s also)
  • Erythema Migrans rash
  • Other Sx (arthralgias, radiculopathy, paresthesias, headache)
  • Children (Bell’s is rare in Peds)
Early Disseminated Lyme often requires IV Antibiotics x 1 mo.
6.  Treat for “Bell’s” if none of above
      Also refer to Neuro:
  • Bilat. Palsy (if not Primary HIV or Lyme)
  • Recurrent Bell’s Palsy
Treatment for Bell’s Palsy  —  Prednisone 60 – 80 mg in 1 daily AM dose
  • Only helps during first few days, not >1 wk.
  • Severe Palsy: Add Acyclovir 800 mg 5x/d, OR Valacyclovir 1000 mg T.I.D.
  • Patch eyelid closed at night, day too if severe palsy (prevent corneal drying)
Send to Neuro if:
  • No improvement at all by 3 mos.
  • Persistent disability at 1 yr.