SPECIAL FEATURE: BELL’S PALSY

BELL’S PALSY: A REVIEW

Bell’s palsy can be a frightening condition for the patient, coming on rapidly and
resulting in noticeable facial paralysis. However, although most people will make
a full recovery, the GP still has an active role in supporting the patient

Bianca CASE STUDY neurons innervating inappropriate muscles, resulting in

Potterton On a Monday morning, a 45-year-old woman abnormal movements or facial synkinesis. Autonomic
MBBS presented to her GP with a left-sided facial dysfunction can occur when fibres intended for salivary
GP registrar, weakness. She had difficulty closing her left eye glands instead reconnect with the lacrimal ducts,
Bridge Lane when putting on make-up in preparation for an causing lacrimation while eating – the phenomenon
Surgery, evening out on Friday; over the weekend the nicknamed “crocodile tears”.1,5
London weakness had progressed to involve the whole of The first documentation of facial nerve paralysis
the left side of her face. She had been diagnosed in medical literature was in 1798 by Nicolaus Anton
with Bell’s palsy 10 years previously, so decided Friedrich, a German pathologist at the University
not to seek medical attention over the weekend, of Wurzburg, who described three cases of acute
but to wait until Monday. When seen by her GP, unilateral facial paralysis. Twenty years later, the
she had a marked left-sided facial paralysis. There
Scottish surgeon and anatomist Sir Charles Bell was
was no other limb weakness or focal neurology.
the first to delineate the anatomy of the facial nerve.
A diagnosis of Bell’s palsy was made and
In his paper of 1821, titled On the Nerves: Giving an
treatment with prednisolone commenced. When
she returned to her GP six weeks later she had
Account of some Experiments on Their Structure and
made a near, but not complete, recovery. She was Functions, Which Lead to a New Arrangement of the
pleased with how quickly and her facial paralysis System, he described the disease of unilateral facial
had recovered and not troubled by the small paralysis, or Bell’s palsy.1
degree of remaining weakness. She was instead
more concerned by the cold sore on her upper lip Aetiology
which had become infected, her primary reason Bell’s palsy is diagnosed when no other medical
for re-attendance. aetiology is identified as a cause of the facial weakness.5
Until recently Bell’s palsy has been considered
idiopathic, although more recently a viral aetiology has
Bell’s palsy is an acute ipsilateral paralysis of the been proposed. The viruses most frequently implicated
seventh cranial nerve (the facial nerve), characterised are Herpes Simplex Virus Isoform -1 (HSV-1) and
by a sudden onset facial weakness that progressively
worsens over 48 hours, followed by a gradual recovery,
usually over the next three weeks.1 Bell’s palsy affects Even without treatment
11–40 people per 100,000 per year, or 1 in 5,000.2
The peak incidence is between the ages of 15 and complete recovery will
50, although younger children can also be affected.2,3 occur in 70% of cases,
The incidence is slightly increased in pregnancy (45 per
100,000).3 The recurrence rate is 12%, with a 36% and near-complete
recurrence rate on the same side.1 Risk factors include
diabetes, hypertension, hypothyroidism,1 obesity and
recovery in 85%
a compromised immune system.4 A family history
is present in 4-8%.1 Multiple recurrences are rare, Herpes Zoster Virus (HZV). This theory dates back to
and recurrence does not seem to be correlated with 1996 when, in a study of 14 patients who presented
prognosis. Rarely, it can occur bilaterally.4 with Bell’s palsy, Murakami et al isolated HSV-1
The prognosis is largely favourable. Even without genomes in the endoneurial fluid of the facial nerve
treatment complete recovery will occur in 70% of and posterior auricular muscle in 79% of patients.6
cases, and near-complete recovery in 85%.4,5 However, When latent, these viruses can be reactivated from the
15% will be left with long-lasting sequelae, which can geniculate ganglion of the facial nerve in the temporal
cause considerable psychological distress. Aberrant bone.1,3,6 The mechanism of injury is a viral-mediated
neural regeneration can result in regenerating motor inflammation which causes oedema of the nerve

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SPECIAL FEATURE: BELL’S PALSY

sheath and compression of the nerve, with or without The important differentiation to make is between
demyelination.7 Facial anatomy may also play a role. a peripheral motor neuron palsy or a central upper
In a study using CT with multiplanar reconstruction motor neuron lesion as the management of each is
(MPR-CT) Murai et al demonstrated that a narrow substantially different. The differentiation can be
facial nerve canal is an additional risk factor.7 Certain made through a careful examination of the cranial
systemic disease processes can predispose patients nerves, in particular cranial nerve VII, the facial
towards Bell’s palsy, most commonly hypertension nerve. Upper motor neuron cortical and sub-cortical
and diabetes2 and less commonly hypothyroidism,2 damage, commonly caused by a middle cerebral artery
sarcoidosis, amyloidosis and Sjogren’s syndrome. stroke causes a contralateral lower two-thirds facial
Pregnancy is also a predisposing factor and a link with palsy which does not affect the frontalis muscle of
hypertensive disease of pregnancy is well-established. the forehead to to bilateral cortical innervation of
Palsies occur more commonly in the third trimester and this muscle: the forehead is “spared” the paralysis.
early post-partum period.8,9 A lower motor neuron facial palsy causes an ipsilateral
Approximately 70% of facial nerve palsies flaccid palsy which affects both the frontalis muscle
are considered to be Bell’s palsy; 30% of patients of the forehead and the lower facial muscles.14 In the
presenting with facial paralysis have other underlying diagnosis of Bell’s palsy the facial weakness affects the
causes.4 Varicella Zoster Virus (VZV) in the geniculate forehead, and the patient loses the ability to raise an
ganglion can also cause a facial paresis (in this eyebrow or wrinkle the forehead, whereas in a cortical
instance it is known as Ramsay Hunt syndrome and stroke the forehead is unaffected. Careful clinical
characterised also by pain and vesicles affecting the assessment is required to make the distinction.
ear). Other infections such as Borrelia burgdoferi, the
bacterium causing Lyme disease, and less commonly The anatomy14,15
Rickettsia10 can also cause a facial paralysis. Lyme The facial nerve (CN VII) is largely composed of
disease is more common in children. In a Finnish study motor fibres. It also carries sensory fibres from the
of 46 children aged 0-16 years in September 2013 anterior two thirds of the tongue and parasympathetic
Kanerva et al noted that Borreliosis was the single most secretomotor fibres to the parotid, sublingual and
common cause of facial palsy with VZV the second. In lacrimal glands, via the greater superficial petrosal
that study, the study hospital was located in a region nerve, and submandibular glands via the chorda
tympani, which conveys taste from the anterior two
thirds of the tongue.
The cranial nerve originates from the facial nerve
nucleus in the brainstem. It takes a winding route
Approximately 70% through the temporal bone, to emerge from the
of facial nerve palsies base of the skull at the stylomastoid foramen via the
fallopian canal. In Bell’s palsy the facial nerve is most
are considered to be commonly compressed at the narrowest segment of the
Bell’s palsy fallopian canal. When the facial nerve emerges from
the stylomastoid foramen, it gives off a number of
branches which innervate most of the muscles of the
face. The posterior auricular nerve supplies part of the
occipitofrontalis muscle of the scalp and the posterior
endemic for Lyme disease.11 Otitis media has also been auricular muscle of the ear. A further branch supplies
implicated, especially in children.2 several muscles of the throat. The nerve then enters the
Other non-infective causes of facial nerve paralysis parotid gland, one of the main salivary glands which
should be considered, especially in the recurring sit underneath the ear. Five terminal branches of the
case. Benign or neoplastic tumours of the head and facial nerve emerge from the parotid gland to supply
neck, specifically those of the parotid gland, posterior most of the muscles of the face, including muscles of
fossa or nerve sheath itself, should be looked for and the forehead, temple, supra-orbital region, cheek, upper
excluded. A longitudinal study performed in Taiwan and lower lips, corner of the mouth, chin and neck.
which followed 2,618 patients with Bells Palsy for
five years after diagnosis demonstrated a statistically Clinical features
significant increased risk of oral cancer in patients It follows that in Bell’s palsy most movements of the
with Bells palsy. face are affected. There is an ipsilateral facial droop
12
Cholesteatoma should be considered in those of the affected side of the face, with drooping of the
whose hearing is affected.3 Bilateral facial nerve eyebrow and corner of the mouth. There is difficulty
paralysis is uncommon, accounting for less than 1% of closing the eyes and blinking, smiling and frowning.
all cases. In these cases Lyme disease,3,10 Guillian-Barre The nasolabial fold is typically absent, and the
and sarcoidosis should all be considered.13 mouth may be drawn toward the unaffected side on
In general practice the diagnosis remains clinical. smiling.1,14 Hearing can be affected due to paralysis

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 SPECIAL FEATURE: BELL’S PALSY

of the stapedius muscle; the most common finding is recovery and reduction of long-term sequelae.4,5,17,18
hyeracusis. Taste may also be altered.1,3 Steroid treatment should be commenced within 72
hours of the onset of symptoms.18 There is no evidence
Diagnosis for use of steroids in children under the age of 16.4 A
A consultation in general practice should include an meta-analysis performed in 2010 looked at seven trials
examination of the cranial nerves, paying attention to with a total of 1,507 participants. When treated with
the extent of facial weakness especially with regards
to the forehead, and examining for the presence of
hearing loss. To exclude other diagnoses, the skin of the
head and face should be assessed and the ear examined
A straightforward
for signs of ear infection. Granulation and pus may diagnosis of Bell’s palsy
indicate cholesteatoma, discharge can point towards
otitis media, while a vesicular rash may indicate
does not require a
Ramsay Hunt syndrome.4 referral to neurology
If HSV1 or VZV are suspected, serology can be
sent for confirmation, although this will not change
management. Serological tests for Lyme disease corticosteroids, 23% of the patients had incomplete
(IgM, IgG) should be used in endemic areas to exclude facial recovery at six months compared with 33% of
the disease. controls: a risk reduction of 71%. The number needed
A number of scoring systems can be used to grade to treat (NNT) for corticosteroids to avoid one patient
facial paralysis. The most commonly used is the House- from suffering incomplete recovery of facial function
Brackmann Scale which has grades from I (normal was 10.5 There is no established treatment regime.
facial movements) to VI (complete paralysis).16 NICE recommends prednisolone. Options include
25mg twice daily for ten days or 60mg daily for five
days, followed by a daily reduction in dose of 10mg for
TABLE 1: HOUSE-BRACKMANN SCALE
a total treatment time of 10 days.19
Even though a viral link is well-established, there is
Grade Definition currently no good evidence for antiviral agents, either
I Normal symmetrical function in all areas alone or in addition to a corticosteroid and there have
been numerous trials on the subject.10,20 A large meta-
II Slight weakness noticeable only on close inspection analysis performed in 2011 looked at studies which
Complete eye closure with minimal effort compared treatment with valaciclovir and aciclovir
Slight asymmetry of smile with maximal effort
and prednisolone to prednisolone alone. It illustrated
Synkinesis barely noticeable, contracture, or spasm absent
that although treatment with a corticosteroid plus an
III Obvious weakness, but not disfiguring antiviral agent may lead to slightly higher recovery
May not be able to lift eyebrow rates at three and six months compared to treating
Complete eye closure and strong but asymmetrical mouth with a corticosteroid alone, the difference was not
movement with maximal effort statistically significant.20
Obvious, but not disfiguring synkinesis, mass movement
or spasm Other treatment
IV Obvious disfiguring weakness Eye care is important. If the patient cannot close the
Inability to lift brow eye the exposed cornea is prone to drying, infection
Incomplete eye closure and asymmetry of mouth with and trauma. Lubricating drops should be prescribed
maximal effort and taping the eye shut at night (placing the tape over
Severe synkinesis, mass movement, spasm a soft pad) should be recommended, with careful
V Motion barely perceptible instruction as to how to prevent further damage. If the
Incomplete eye closure, slight movement corner mouth eye cannot be closed with tape, an urgent referral to
Synkinesis, contracture, and spasm usually absent ophthalmology is advised.7,21
VI No movement, loss of tone, no synkinesis, contracture, A number of other treatments have been tried.
or spasm Physiotherapy is not recommended,2 while surgical
decompression of the facial nerve does little to
alter the prognosis. However, more recently, some
success has been achieved with a small number of
Treatment well-selected cases who had been shown to have an
The most well-established treatment for Bell’s palsy is unfavourable prognosis following electrodiagnostic
corticosteroids, in accordance with the idea that the testing.22,23 Trials of acupuncture as a treatment for
mechanism of injury is an inflammatory-mediated Bell’s palsy indicate that while the available evidence
nerve damage. The available evidence shows significant is broadly in favour of acupuncture, the evidence is of
treatment benefits in terms of both gain of complete poor quality and unreliable.24 Laser therapy has been

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SPECIAL FEATURE: BELL’S PALSY

shown to improve neural regeneration. A recent small

trial using laser therapy on specific points of the face
produced promising results, although further research
A recent small trial using laser
is required.25 therapy on specific points of the face
Referral produced promising results, although
A straightforward diagnosis of Bell’s palsy does not further research is required
require a referral to neurology. However, referral
should be considered for recurrent or bilateral
cases. If the diagnosis is not straightforward, and a
or when there are findings beyond an isolated CN VII
tumour is suspected, the patient should be referred
involvement, should be referred for neuro-imaging and
for neuro-imaging or referred as a fast-track referral
further assessment. The experience can be extremely
to ear, nose and throat or neurology as appropriate.2
frightening for the patient, and reassurance can be
For the few cases of Bell’s palsy which have limited
given that the majority will make a full recovery.
improvement over time, a referral to neurology for
electrodiagnostic testing to assess the extend of nerve
damage is warranted. References
1. Zandian A. et al, Medical Science Monitor. 2014; 20:83-90
Conclusion
2. Teixeira L, Valbuza J, Prado G, Cochrane Database of
Bell’s palsy is not always idiopathic; herpes simplex Systematic Reviews. 2011; (12)CD006283,
virus and herpes zoster virus often play a role. HSV-
3. Holland N, Weiner G, BMJ. 2004; 329(7465):553
1 and VZV serology can be an aid to diagnosis if a
4. Baugh R. et al, Otolaryngol Head Neck Surg, 2013; 149 (3)
viral aetiology is suspected. Although this does not
(suppl S1-S27)
currently change management, it can help the patient
5. Salinas R, Alvarez G, Daly F, Ferreira J, Cochrane Database of
to better understand their disease. Other causes of
Systematic Reviews. 2010; (3)CD001942
facial nerve paralysis should be carefully looked for
6. Shingo Murakami, et al, Ann Intern Med. 1996;124(1) Part1
and excluded, while Lyme disease and otitis media
should be considered in children. It is worth checking 7. Murai A, et al, European Archives of Oto-Rhino-Laryngology,
2013; 270(7):2035-8
blood pressure and assessing for diabetes in all who
present with Bell’s palsy. In adults over the age of 16 8. Klein, A, Clinical Obstetrics and Gynecology, 2013: 56(2);
382–388
years, corticosteroid treatment should be commenced
within 72 hours of onset of symptoms. Those cases 9. Shmorgun D, Chan W-S, Ray J.G, QJM, 2002, (95) 359-62
in which the history and examination findings point 10. Nilsson K, et al, European Journal of Neurology. 2014;
21(2):206-14
towards an upper motor neuron facial nerve paralysis,
11. Kanerva M, et al, Otology & Neurotology, 2013; 34(7), 82–87

SUMMARY OF KEY POINTS 12. Sheu J, Keller J, Lin H, J Neurooncol, 2012; 110(2) 215-20
13. Tiemstra J, Khatkhate N, Am Fam Physician, 2007;

1 Bell’s palsy is not always idiopathic: HSV and HZV are the two
main viral causes
76(7):997-1002.
14. Bhatti M, et al, Curr Neurol Neurosci Rep, 2010; 10:448–458
15. Drake R, Vogl W, Mitchell A, Gray’s Anatomy for Students
2 In addition to an examination of the cranial nerves, examine
the ear, parotid gland and skin of the face, head and neck
(2005) Philadelphia, Elsevier, p 821
16. House JW, Brackman DE, House Brackman Facial Nerve
Grading System 2010.
3 Check blood pressure and look for diabetes in all who present
with Bell’s palsy
17. Gronseth G, Paduga R, Neurology. 2013; 79(22):2209-13
18. Berg T, et al, Archives of Otolaryngology - Head & Neck
Surgery. 2012; 138(5):445-9
4 Exclude Lyme disease and otitis media in children
19. Nice clinical Knowledge summary: http://cks.nice.org.uk/
bells-palsy [last accessed February 2015]
5 Treat with corticosteroids within 72 hours of onset of
symptoms
20. Numthavaj P, Thakkinstian A, Dejthevaporn C, Attia J, BMC
Neurology, 2011; 11:1 1-10
21. Mooney T, Nursing Standard. 2013 Dec; 28(14):44-9
6 A treatment regime suggested by NICE is: prednisolone
60mg a day for five days followed by a reduction of 10mg a 22. McAllister K, Walker D, Donnan P, Swan I, Update of
day for a ten day total course Cochrane Database Syst Rev. 2011;(2):CD007468; PMID:
21328293]

7 Remember eye care: lubricant drops 23. Bodénez C, et al, J Laryngol Otol. 2010 Mar;124(3):272-8
24. Chen N, Zhou M, He L, Zhou D, Li N, Cochrane Database of

8 Refer recurrent or bilateral Bell’s palsy for neuro-imaging and

further assessment
Systematic Reviews. 2010 (8) CD002914
25. Salaheldien M, Alayat M, Elsodany A, El Fiky A, Lasers Med
Sci, 2014; 29:335–342

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