Bell’s Palsy in the ED

When you walk into a patient’s room and see this:

What should you do?

1. As with every patient, make sure they are maintaining their ABCs.
2. Do a neurological exam – this is very important for you to differentiate between a stroke and a peripheral nerve palsy.
3. Don’t panic!

BELL’S PALSY

Bell’s Palsy (sometimes called idiopathic facial nerve palsy) is a rare, peripheral facial nerve paralysis that can present in patients of any age, race, or health status. Patients often complain of an inability to move their face, but can also describe numbness, blurred vision or dry eyes, hyperacusis, dry mouth, and changes in taste. This is because the facial nerve (CN VII) has branches that supply the ear (nerve to stapedius) and the anterior ⅔ of the tongue (via the lingual nerve).

Anatomy of the Facial Nerve (Image from https://neupsykey.com/wp-content/uploads/2016/07/10FF1.jpg)

Your role is to differentiate Bell’s Palsy from a stroke. The neurological exam is key. In Bell’s Palsy or any peripheral facial neuropathy, the ipsilateral forehead muscles should be paralyzed. A central lesion would show forehead sparing, since the forehead muscles receive nerve fibers from both hemispheres of the brain. 

Innervation of the Facial Muscles, (from https://www.ebmconsult.com/articles/anatomy-stroke-vs-bells-palsy)

As shown in the diagram, the muscles of the forehead receive nerve fibers from both halves of the brain. A central lesion could impair the function of one hemisphere’s “forehead fibers,” but the muscles would still have innervation from the contralateral facial nucleus. A peripheral facial nerve lesion involves the nerve after all roots have already combined, and thus a peripheral facial nerve palsy paralyzes the ipsilateral forehead.

You can test this by having a patient attempt to raise their eyebrows. If they are able to symmetrically raise their eyebrows but the lower face remains weak or paralyzed, you should be concerned about a central process. Many patients with Bell’s Palsy will also be unable to fully close the eye.

Most commonly, Bell’s Palsy is thought to be caused by a reactivation of a herpes virus. However, it can also be caused by Lyme disease (pathognomonic when bilateral), sarcoidosis, HIV, or salivary gland tumors that compress the nerve.

TREATMENT

The primary treatment for Bell’s Palsy is steroids. Current guidelines recommend prednisone, 60 to 80 mg daily, for one week (3). Steroids have been shown to increase the chance of full recovery, particularly if started within 3 days of onset of symptoms. A systematic review found a significant reduction in patients unsatisfied with their facial recovery if they were treated with prednisone (RR 95% confidence interval 0.55-0.87). It also found that in patients with severe facial nerve palsy, prednisone use had a number needed to treat of 11 for recovery of function (2).

The data for antiviral treatment is less convincing. In 2007, a randomized controlled trial from Scotland compared almost 500 patients with Bell’s Palsy of less than 72 hours’ duration in four groups: 1) prednisolone and acyclovir, 2) prednisolone and placebo, 3) acyclovir and placebo, and 4) two placebos. The study found that patients treated with prednisolone showed a higher rate of complete recovery of facial function at 3 months when compared with patients who did not receive prednisolone (83.0% vs. 63.6%, p < 0.001). Acyclovir had no impact on the recovery of facial nerve function (71.2% vs. 75.7%, p = 0.30). In the two groups treated with prednisolone, the addition of acyclovir had no statistically significant impact on recovery (5).

In 2008, a similar randomized, double-blinded, placebo-controlled trial included over 800 adult patients with Bell’s Palsy (4). The study compared four groups of about 200 people each: 1) two placebos, 2) prednisolone plus placebo, 3) valacyclovir plus placebo, and 4) prednisolone and valacyclovir. The study found a significant reduction in the time to recovery for the two groups treated with prednisolone, but no change in recovery time in the groups treated with valacyclovir. A more recent systematic review found a modest decrease in unsatisfactory recovery with the addition of valacyclovir to a steroid regimen (RR 0.75); however, this difference did not reach statistical significance (2). It’s important to highlight the choice of “decrease in unsatisfactory recovery”, as this may not translate directly into an increase in patient satisfaction or actual recovery. If you are planning to treat with valacyclovir, consider checking baseline renal function, as side effects have been observed more commonly in patients with kidney disease and in the elderly. Make sure to also tell your patients to hydrate when taking valacyclovir, as the medication can precipitate in the renal tubules.

Remember to protect the eye on the affected side with artificial tears, nightly lubricant, or an eye patch if possible, as many patients will complain of dry eye. Difficulty with fully closing the lids puts patients at risk for corneal abrasions, foreign bodies, and other ocular trauma.

Patients with Bell’s Palsy need appropriate follow up with a neurologist and sometimes an ophthalmologist. Most patients recover at least some facial nerve function, but the recovery can take months. Make sure to counsel your patients and give return precautions, especially regarding new neurological symptoms.

REFERENCES

1. 1. Busti AJ, Kellogg, D. Stroke vs. Bell’s Palsy. Evidence-Based Medicine Consult. July 2015. Online. https://www.ebmconsult.com/articles/anatomy-stroke-vs-bells-palsy
2. 2. De Almeida JR, et al. Combined Corticosteroid and Antiviral Treatment for Bell Palsy: A Systematic Review and Meta-Analysis. JAMA. 2009; 302(9): 985-93. Online. https://pubmed.ncbi.nlm.nih.gov/19724046/
3. 3. De Almeida JR, et al. Management of Bell Palsy: clinical practice guideline. CMAJ. 2014; 186(12): 917-922. Online. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4150706/
4. 4. Engström M, et al. Prednisolone and Valacyclovir in Bell’s Palsy: A Randomised, Double-Blind, Placebo-Controlled, Multicentre Trial. Lancet Neurol. 2008; 7(11): 993-1000. Online. https://pubmed.ncbi.nlm.nih.gov/18849193/
5. 5. Sullivan FM, et al. Early Treatment with Prednisolone or Acyclovir in Bell’s Palsy. NEJM. 2007; 357:1598-1607. Online. https://www.nejm.org/doi/full/10.1056/NEJMoa072006

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David Warshaw

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