Ear, Nose & Throat
Question 112 of 300
A 74 year old woman presents to the Emergency Department with a 12 hour history of right sided facial weakness. On examination you note right facial muscle weakness - she is unable to raise her eyebrow on the right side. There are no focal neurological signs otherwise. Which of the following drugs is indicated in this patient?
Answer:
The patient has signs and symptoms of Bell's Palsy. For people presenting within 72 hours of the onset of symptoms, consider prescribing prednisolone. There is no consensus regarding the optimum dosing regimen, but options include giving 50 mg daily for 10 days, or giving 60 mg daily for five days followed by a daily reduction in dose of 10 mg (for a total treatment time of 10 days) if a reducing dose is preferred.Bell's Palsy
Ear, Nose & Throat
Last Updated: 12th February 2021
Bell’s palsy is an acute, unilateral, idiopathic, isolated, lower motor neuron facial nerve paralysis. The cause of Bell's palsy is unknown. Herpes simplex virus, varicella zoster virus, and autoimmunity may contribute to the development of Bell's palsy, but the exact pathogenesis is controversial and the significance of these factors remains unclear.
Epidemiology
Overall, Bell's palsy is relatively uncommon, affecting 20–30 people per 100,000 each year. Men and women are equally affected. It occurs more commonly in people who:
- Are aged between 15 and 45 years.
- Have diabetes, immunocompromise, obesity, hypertension, or upper respiratory conditions.
- Are pregnant.
Diagnosis
Take a history and perform a focused examination of the scalp, ears, mastoid region, parotid glands, oral cavity, eyes, and cranial nerves.
- A diagnosis of Bell's palsy can be made when no other medical condition is found to be causing facial weakness or paralysis.
- Symptoms suggestive of Bell's palsy include:
- Rapid onset (less than 72 hours).
- Facial muscle weakness (almost always unilateral) involving the upper and lower parts of the face. This causes a reduction in movement on the affected side, often with drooping of the eyebrow and corner of the mouth and loss of the nasolabial fold.
- Ear and postauricular region pain on the affected side (in around half of people with Bell's palsy).
- Difficulty chewing, dry mouth (in 20%), and changes in taste (in around 35%).
- Incomplete eye closure, dry eye (in 30%), eye pain, or excessive tearing.
- Numbness or tingling of the cheek and/or mouth.
- Speech articulation problems, drooling.
- Hyperacusis (in less than 5%).
- Symptoms atypical of Bell's palsy and thus suggestive of an alternative diagnosis include:
- Insidious and painful onset. Gradual progression is more likely to be associated with a neoplastic or infectious cause of facial palsy.
- A progressive and prolonged (more than 3 months) duration of symptoms with frequent relapses (indicative of a neoplastic process).
- Predisposing factors for facial palsy, for example, previous stroke, brain tumour, parotid tumour, skin cancers of the head and face, or facial trauma.
- Systemic illness or fever.
- Vestibular or hearing abnormalities (other than hyperacusis), otorrhoea, diplopia or dysphagia.
- Sparing of forehead movement (which may indicate an upper motor neurone lesion such as stroke) and bilateral signs (may be indicative of Lyme disease or sarcoidosis). Lower motor neurone lesions (such as Bell's palsy) do not spare the upper face.
- A recurrent episode.
- Paralysis of individual branches of the facial nerve or other cranial nerve involvement.
- Parotid gland masses, vesicular skin rashes, and lesions suggestive of skin cancer.
Routine laboratory tests and diagnostic imaging are not required for new-onset Bell's palsy.
Differential diagnosis
Other causes of facial weakness and paralysis:
- Stroke
- Brain tumour
- Traumatic injury to facial nerve
- Facial nerve tumour, skin cancer, parotid tumour
- Diabetes mellitus
- Multiple sclerosis
- Guillain-Barré
- Sarcoidosis
- Arteriovenous malformation
- Infectious causes:
- Herpes simplex
- Lyme disease
- Otitis media
- Mastoiditis
- Cholesteatoma
- Ramsay-Hunt syndrome
- Encephalitis/meningitis
- HIV
- Syphilis
- Glandular fever
Management
- Reassure patients that the prognosis is good and most people with Bell’s palsy make a full recovery within 3 - 4 months.
- Advise the person that they should keep the affected eye lubricated with drops during the day and ointment at night, and that if they are unable to close the eye at night, they should tape it closed using microporous tape. Situations that may cause eye irritation such as swimming and dusty environments should be avoided if possible.
- For people presenting within 72 hours of the onset of symptoms, consider prescribing prednisolone. There is no consensus regarding the optimum dosing regimen, but options include giving 50 mg daily for 10 days, or giving 60 mg daily for five days followed by a daily reduction in dose of 10 mg (for a total treatment time of 10 days) if a reducing dose is preferred.
- Antiviral treatments alone are not recommended. Antiviral treatment in combination with a corticosteroid may be of small benefit, but seek specialist advice if this is being considered.
Complications
Complications of Bell's palsy include:
- Eye injury, corneal ulceration, and vision loss because of an inability to close the eyelid
- Facial pain and paraesthesia
- Dry mouth because of loss of parasympathetic innervation to the submandibular and sublingual salivary glands
- Intolerance to loud noises if the nerve branch to stapedius is affected
- Synkinesis — abnormal facial muscle contraction during voluntary movements (for example, facial spasms such as involuntary eye closure during midface movement, or lip movement when the eyes close), possibly as a result of unusual reinnervation of the facial musculature
- Psychological impact of facial disfigurement
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
