Bell’s Palsy

Patient Presentation:
A 20-year-old male, N.R., presents at the health clinic complaining of difficulty chewing on the right side of his mouth X 1 day, with loss of motor function within two hours. Also states he cannot whistle and his face ‘feels uncoordinated’ on the right side. Pt reports he is recovering from the ‘worst flu he has ever had’ with a severe sore throat, fever, and headache, with onset about ten days ago. N.R. states he experienced significant pain behind his right ear two days ago.

Diagnosis:
Upon examination, N.R. is diagnosed with Bell’s Palsy, Grade I on the House-Brackmann scale (grading system of I-IV denoting severity and prognosis), due to sudden onset, history of URI, unilateral partial paralysis of the face, and patient’s report of post-auricular pain. Neurological examination, including all remaining cranial nerves, yields no further findings of deficits. Pt is asked to check in with clinic on a daily basis to monitor progress of paralysis. Within 8 days, near total paralysis of the right side of the face is evident, now Grade III-IV on the House-Brackmann scale, including loss of taste, drooping mouth and eyelids, flattening of the naso-labial fold, inability to close the right eye with the eyeball turning upwards when pt attempts to close eye, loss of lacrimation, drooling, loss of ability to chew, smile or frown. Marked right sided facial swelling is also evident.

Treatment:
Due to significant progression of symptoms, it is assumed that the lesion of facial nerve is nearly full. Discussion is had with patient of performing electromyography studies to see if there is evidence of electrical activity when pt attempts voluntary movement, thus confirming or denying that nerve is still intact, with uninterrupted pathway. Another possibility for diagnosis/prognosis is motor nerve conduction studies to determine the difference in electrical activity between the two sides of the face, with stimulation of the facial nerve, to estimate neuron loss. Also discussed is the option of starting on a glucocorticoid (prednisone) and an anti-viral (valacyclovir) but it is decided to wait one week to see if paralysis starts to resolve. In the meantime, N.R. is told to protect face from cold and to wrap face when outside due to hyperesthesia, as it is wintertime in a cold climate, to instill artificial tears hourly and wear protective glasses when awake, and to use ointment at night with an eye patch, to decrease the risk of corneal irritation and abrasion. Vigilance with oral hygiene, with frequent checking of oral mucosal membranes, is also reviewed.

Prognosis:
Progression of the paralysis stopped within ten days from onset. At day 14, slight partial movement started to return but recovery of controlled movement was slow. Based on the beginning of the reversal of paralysis after only two weeks, the prognosis was good for a complete recovery within six months. Pt was instructed to receive physical therapy of the facial muscles once the acute phase was over; with frequent re-checks at the clinic during the recovery phase.

Extra facts:

Bell’s Palsy, unilateral sudden-onset paralysis of Cranial Nerve VII or the facial nerve, can be caused by infection (likely candidate is herpes simplex virus), trauma, or compression of the nerve.
Most cases of Bell’s palsy have symptoms that start to resolve within three weeks of onset, with full recovery within 6 months. Full recovery is more common if there was only partial involvement of the nerve.
Residual and permanent effects can include decreased taste sensation and hypersensitivity to noise on the same side of the Bell’s palsy, as well as some degree of paralysis.
In severe cases, permanent erroneous facial neural impulses may occur due to a chaotic and disorganized regeneration of the part of cranial nerve VII that was affected (e.g. the eye may wink when a recovered patient expresses emotion with their mouth).