Bell’s Palsy (Cranial Nerve VII Palsy)

Bell’s palsy is a diagnosis of exclusion with a very acute/abrupt onset of paresis/paralysis with maximum
onset occuring within 72 hours with some recovery within 2 to 3 weeks after onset of symptoms and complete
recovery within 3 to 4 months. The underlying pathophysiology observed in post-mortem cases of Bell’s palsy is
vascular distension, inflammation and oedema with ischaemia of the facial nerve. The aetiology remains unclear.
Various causes have been proposed including viral, inflammatory, autoimmune and vascular. However, reactivation
of herpes simplex virus or herpes zoster virus from the geniculate ganglion is suspected to be the most likely cause.
Corticosteroids and antiviral medications are the most commonly used medical therapies.

Clinical Features Risk Factors:

● Weakness or paralysis of the upper and lower ● Pregnancy

facial muscles of the affected side ● Severe preeclampsia
● Drooping of ipsilateral eyelids ● Obesity
● Inability to close the eye completely
● Hypertension and chronic hypertension
● Dry eye due to inability to close eyes completely
● Excessive tearing of the eye (epiphora) ● Diabetes
● Drooping of the corner of the mouth ● Upper respiratory ailments
● Ipsilateral impaired/loss of taste sensation
● Difficulty with eating due to ipsilateral muscle
weakness causing food to be trapped on the
affected side of the mouth
● Dribbling of saliva
● Altered sensation on the affected side of the face
● Pain in or behind the ear
● Increased sensitivity to sound (hyperacusis) on
affected side if stapedius muscle is involved

Differential Diagnoses Complications

1. Neurologic: Stroke (Upper motor neuron
palsy), Guillain-Barre Syndrome, multiple
Sclerosis
2. Otologic: Acute or Chronic Otitis Media,
Malignant/necrotising otitis Externa,
Cholesteatoma, Schwannoma
3. Infectious: Herpes Zoster Virus (Ramsay Hunt
syndrome), Mumps, Rubella, Epstein Barr
Virus
4. Inflammatory: Sarcoidosis
5. Neoplastic: Cerebral Tumour, Cutaneuos
● motor synkinesis (involuntary movement of
muscles occurring at the same time as deliberate
movement, e.g. involuntary mouth movement
during voluntary eye closure)
● crocodile tears (tears when eating due to
misdirection of regenerating gustatory fibres
destined for the salivary glands, so that they
become secretory fibres to the lacrimal gland and
cause ipsilateral tearing while the patient is eating)
● incomplete recovery
 Cancer of the face and neck, Parotid Tumor, ● contracture of facial muscles
Metastatic Tumor, Lymphoma
6. Trauma- Temporal bone fractures, post-
● reduction or loss of taste sensation
surgical injuries ● problems with dysarthria due to facial muscle
weakness.
● Ocular problems

How to test Cranial Nerve VII?

Inspection: facial asymmetry, facial tics, symmetry of eye blinking or eye closure, smiling, skin lesion especially of
the ears
Motor Testing:

Instruction Muscle tested Response in palsy

Asymmetry as he/she cannot

Ask the patient to wrinkle his/her
Frontal belly of occipito-frontalis wrinkle his forehead on the side of
forehead
palsy in LMN palsy

In LMN palsy eyelids dell’s

Ask the patient to close his/her
eyes forcibly while you try to open
the eyelids with your fingers
phenomenon. In healton’t close
completely. Instead the eyeball rolls
Orbicularis oculi up. This is known as Bhy
individuals, eyelids cannot be
opened with mild force against
patient’s resistance.

Levator anguli oris, Zygomatic

Ask the patient to show his/her Angle of mouth deviates towards
major and minor, Depressor anguli
teeth or smile normal side
oris, Buccinator, Risorius

Ask the patient to blow out cheeks

with mouth closed i.e puff the
Patient can’t blow out his cheek as
cheeks and assess power by your Orbicularis oris, Buccinator
air escapes from affected side
attempt to deflate the cheek
Ask the patient to whistle

Ask the patient to clench his/her

Folds of platysma is seen in the
teeth and simultaneously depress Platysma
neck as platysma contracts
the angles of mouth

Sensory Testing:
1. Taste Discrimination- Chorda tympani
2. Corneal reflex (Trigeminal nerve afferent while Facial nerve efferent)
3. Schirmer’s Test- greater petrosal nerve
4. Audiologic Testing (Hyperacusis)-Stapedial nerve

GRADE CHARACTERISTICS

I. Normal Normal facial function in all areas

 II. Mild Dysfunction Gross
Slight weakness noticeable on close inspection
May have slight synkinesis
At rest, normal symmetry and tone
Motion
Forehead - Moderate to good function
Eye - Complete closure with minimal effort
Mouth - Slight asymmetry

III. Moderate dysfunction Gross

Obvious but not disfiguring difference between sides
Noticeable (but not severe) synkinesis, contracture, or hemifacial spasm
At rest, normal symmetry and tone
Motion
Forehead - Slight to moderate movement
Eye - Complete closure with effort
Mouth - Slightly weak with maximum effort

IV. Moderately severe Gross

dysfunction Obvious weakness and/or disfiguring asymmetry
At rest, normal symmetry and tone
Motion
Forehead - None
Eye - Incomplete closure
Mouth - Asymmetrical with maximum effort

V. Severe dysfunction Gross

Only barely perceptible motion
At rest, asymmetry
Motion
Forehead - None
Eye - Incomplete closure
Mouth - Slight movement

VI. Total Paralysis No movement

Red Flags In Clinical Examination:

1) facial pain
2) limb weakness
3) paresthesia of the face of limbs
4) cerebellar signs
5) involvement of other cranial nerves
6) gradual onset of facial weakness
7) previous history of facial weakness
8) previous history of regional skin cancer
9) prolonged facial paralysis beyond 6 months

Management of Bell’s Palsy

● Prednisolone should be used in all patients with facial palsy of less than 72 h duration who do not have
contraindications to steroid therapy.
● The prednisolone dose 60 mg per day ( 1mg/kg/day up to a maximum of 80 mg ) for 5 days then reduced by 10
mg per day (for a total treatment time of 10 days)and 50 mg per day (in two divided doses) for 10 days.
● Aciclovir (400 mg five times daily for five days) or valaciclovir (1000 mg/day for five days) should not be given
routinely and treatment unless with known Herpes Zoster Virus infection because it has no proven additional
benefit even if combined with prednisolone
● Ocular Protective Therapy: preservative-free artificial tear during daytime and ointment during sleep
● Refer to: neurologist, ophthalmologist, otolaryngorhinologist, physiotherapist
● Physical therapies including tailored facial exercises, acupuncture to affected muscles, massage, thermotherapy
and electrical stimulation have been used to hasten recovery