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Peripheral Facial Paralysis

Essentials

  • Peripheral facial paralysis is often idiopathic (known as Bell's palsy) but it may also be caused by the herpes virus, borreliosis, otitis, trauma or, in rare cases, by a tumour.
  • The diagnosis of Bell's palsy is made by excluding other causes.
  • An adult with a characteristic Bell's palsy can be examined and treated in primary care. If recovery starts quickly within a few weeks and the patient makes a full recovery, no further investigations are needed.
  • If peripheral facial paralysis is prolonged or the clinical picture is atypical, the patient should be referred to an ear, nose and throat (ENT) specialist for investigations and treatment. Paediatric patients should always be referred for emergency consultation of an ENT specialist and/or a paediatrician.

Symptoms and workup

  • The function of face muscles is either impaired or absent, usually on one side, only. On the affected side, raising of the eyebrow and wrinkling of the forehead are impaired, the eye cannot be properly closed, and raising the angle of the mouth (smiling, grimacing) and pursing of the lips to whistle are either impaired or impossible.
  • The degree of paralysis may vary in different parts of the face, and it may become worse during the first couple of days. It may be difficult to distinguish Bell's palsy from central paralysis at first if there is some paralysis in the mouth area, already, but the eyes can still be closed. If so, ask the patient to blink his/her eyes more rapidly; if the eye on the affected side lags behind, the eye area is involved in the paralysis.
    • In small children, in particular, in whom facial function must be defined from the child's spontaneous facial expressions or while the child is crying, isolated weakness of the inferior branch of the facial nerve is often misinterpreted. As the function of the facial nerve is impaired, the lower lip turns towards the teeth and the angle of the mouth on the unaffected side is pulled downward when the child cries while the angle on the affected side does not move. The angle of the mouth on the unaffected side can therefore be misinterpreted as drooping as a sign of paralysis.
  • Facial paralysis is often associated with taste disturbances, decreased secretion of tear fluid, pain around the ear and headache on the affected side, and failure of the stapedial reflex to occur, making loud sounds even louder.
  • Examine the ears to exclude acute or chronic inflammation and other diseases, and perform tuning fork tests (pictures ) in order to test hearing.
  • Palpate the parotid glands to exclude tumours.
  • Look for blisters signifying a herpes infection (see Shingles).
  • If the patient has a history of cancer, which could have recurred or metastasized to the head area, or if the ear on the side affected by the paralysis has been operated on, be very careful before diagnosing Bell's palsy.
  • Central facial paralysis (dysfunctional lower part of the face but functional forehead and eye areas) always requires neurological examination.

Treatment

  • The treatment consists of prevention of eye dryness by using moisturizing eye drops and by protecting the eye (can be taped closed for the night) http://www.dynamed.com/condition/bell-palsy#CORNEAL_PROTECTION.
  • If the cause of the facial paralysis can be established, treatment should be provided according to the cause.
  • Paralysis causes both physical strain (dysfunctional eye affecting screen work, for example, dysfunctional mouth affecting eating, drinking, etc.) and mental strain (visible to anyone, disfiguring effect). The patient needs support and in the initial phase possibly sick leave.
  • Cooperation with an ENT specialist (botulin injections, for example), ophthalmologist or plastic surgeon (eyelid weights, eyelid surgery, dynamic and static reconstructive surgery, etc.) may be needed to deal with any sequelae.

Bell's palsy Acupuncture for Bell's Palsy, Physical Therapy for Bell's Palsy (Idiopathic Facial Paralysis)

  • Patients older than 16-18 years benefit from treatment with an oral glucocorticoid started as early as possible (preferably within less than 48-72 hours) Corticosteroid Treatment for Idiopathic Facial Paralysis (Bell's Palsy) http://www.dynamed.com/condition/bell-palsy#CORTICOSTEROIDS (60 mg prednisolone once daily for 5 days, the dose subsequently reduced by 10 mg/day; total duration of treatment 10 days) 54.
  • It is unclear whether antiviral medication (such as 1 g valaciclovir 3 times daily for 7 days) combined with a glucocorticoid promotes recovery (antiviral medication alone does not help) http://www.dynamed.com/condition/bell-palsy#ANTIVIRALS. The practice concerning routine use of antiviral medication varies between countries 3.
  • There is a large randomized and double-blind trial taking place in Sweden on glucocorticoid therapy of children with Bell's palsy and borreliosis-associated peripheral facial paralysis 2.
    • The results will be significant, as no study has been published with a study design and patient numbers sufficient to make reliable recommendations.
    • A recent New Zealand study 1 found that prednisolone treatment was not beneficial in Bell's palsy in children, but the number of patients and follow-up time were insufficient to draw reliable conclusions.
  • The prognosis of Bell's palsy is good both in adults and children, but in about one third of the patients some degree of residual disturbance in the functions of the face will remain, mostly mild.

Differential diagnosis

  • Borreliosis (see also Lyme Borreliosis (LB))
    • To be remembered as a possible cause of facial paralysis especially when this occurs during the summertime or in the early autumn, but it is not excluded at other times either.
    • In bilateral paralysis, borreliosis should be primarily suspected.
    • In endemic regions, up to 30% of cases of facial paralysis in children and approximately 3% of those in adults are due to borreliosis.
    • The diagnosis is confirmed by serology and cerebrospinal fluid tests.
    • Treatment consists of antibiotic medication to prevent late symptoms.
  • Shingles (see also Shingles (Herpes Zoster))
    • Causes the so called Ramsay Hunt syndrome (facial paralysis + shingles).
    • In addition to facial paralysis, the symptoms and signs include vesicles on the earlobe and in the outer auditory canal, on the tympanic membrane, oral mucosa, the face or shoulders.
    • The vesicles may precede facial paralysis (by as much as several weeks), occur concomitantly with it or appear only after the onset of paralysis.
    • May be associated with vertigo and impaired hearing.
    • Treatment should consist of a glucocorticoid (as in Bell's palsy, for 10 days) and 1 g oral valaciclovir 3 times daily for 7 days Aciclovir for Ramsay Hunt Syndrome
  • If the facial paralysis does not represent typical Bell's palsy, or if it has not significantly improved within 3 months or recurs rapidly on the same side, MRI of the head may be required, using thinner slices along the whole course of the facial nerve.

    References

    • Babl FE, Herd D, Borland M, et al. Efficacy of Prednisolone for Bell Palsy in Children: A Randomized, Double-Blind, Placebo-Controlled, Multicenter Trial. Neurology 2022;(): [PubMed]
    • Karlsson S, Arnason S, Hadziosmanovic N, et al. The facial nerve palsy and cortisone evaluation (FACE) study in children: protocol for a randomized, placebo-controlled, multicenter trial, in a Borrelia burgdorferi endemic area. BMC Pediatr 2021;21(1):220 [PubMed]
    • Gagyor I, Madhok VB, Daly F, et al. Antiviral treatment for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev 2019;9(9):CD001869 [PubMed]
    • Sullivan FM, Swan IR, Donnan PT, et al. A randomised controlled trial of the use of aciclovir and/or prednisolone for the early treatment of Bell's palsy: the BELLS study. Health Technol Assess 2009;13(47):iii-iv, ix-xi 1-130. [PubMed]
    • Engström M, Berg T, Stjernquist-Desatnik A, et al. Prednisolone and valaciclovir in Bell's palsy: a randomised, double-blind, placebo-controlled, multicentre trial. Lancet Neurol 2008;7(11):993-1000. [PubMed]