Bell's palsy

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Bell's palsy
Classification and external resources

A person attempting to show his teeth and raise his eyebrows with Bell's palsy on his right side. ICD-10 G51.0 ICD-9 351.0 DiseasesDB 1303 MedlinePlus 000773 eMedicine emerg/56 MeSH D020330 Bell's palsy is a form of facial paralysis resulting from a dysfunction of the cranial nerve VII (the facial nerve) that results in the inability to control facial muscles on the affected side. Several conditions can cause facial paralysis, e.g., brain tumor, stroke, and Lyme disease. However, if no specific cause can be identified, the condition is known as Bell's palsy. Named after Scottish anatomist Charles Bell, who first described it, Bell's palsy is the most common acute mononeuropathy (disease involving only one nerve) and is the most common cause of acute facial nerve paralysis. Bell's palsy is defined as an idiopathic unilateral facial nerve paralysis, usually self-limiting. The hallmark of this condition is a rapid onset of partial or complete palsy that often occurs overnight. In rare cases (1%), it can occur bilaterally resulting in total facial paralysis.[1] It is thought that an inflammatory condition leads to swelling of the facial nerve. The nerve travels through the skull in a narrow bone canal beneath the ear. Nerve swelling and compression in the narrow bone canal are thought to lead to nerve inhibition, damage or death. No readily identifiable cause for Bell's palsy has been found. Corticosteroids have been found to improve outcomes while anti-viral drugs have not.[2] Early treatment is necessary for steroids to be effective. Most people recover spontaneously and achieve near-normal to normal functions. Many show signs of improvement as early as 10 days after the onset, even without treatment. Often the eye in the affected side cannot be closed. The eye must be protected from drying up, or the cornea may be permanently damaged resulting in impaired vision. In some cases denture wearers experience some discomfort.

Contents
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1 Signs and symptoms 2 Cause 3 Pathology 4 Diagnosis 5 Treatment

5.1 Steroids 5.2 Antivirals 5.3 Surgery 5.4 Complementary therapy 5.5 Physiotherapy

6 Prognosis 7 Epidemiology 8 History 9 See also 10 References 11 External links

[edit] Signs and symptoms

Facial nerve: the facial nerve's nuclei are in the brainstem (they are represented in the diagram as a ). Orange: nerves coming from the left hemisphere of the brain.Yellow: nerves coming from the right hemisphere of the brain. Note that the forehead muscles receive innervation from both hemispheres of the brain (represented in yellow and orange). Bell's palsy is characterized by facial drooping on the affected half, due to malfunction of the facial nerve (VII cranial nerve), which controls the muscles of the face. Facial palsy is typified by inability to control movement in the facial muscles. The paralysis is of the infranuclear/lower motor neuron type. The facial nerves control a number of functions, such as blinking and closing the eyes, smiling, frowning, lacrimation, salivation, flaring nostrils and raising eyebrows. They also innervate the stapedial (stapes) muscles of the middle ear and carry taste sensations from the anterior twothirds of the tongue.

Clinicians should determine whether the forehead muscles are spared. Due to an anatomical peculiarity, forehead muscles receive innervation from both sides of the brain. The forehead can therefore still be wrinkled by a patient whose facial palsy is caused by a problem in one of the hemispheres of the brain (central facial palsy). If the problem resides in the facial nerve itself (peripheral palsy) all nerve signals are lost on the ipsilateral (same side of the lesion) half side of the face, including to the forehead (contralateral forehead still wrinkles). One disease that may be difficult to exclude in the differential diagnosis is involvement of the facial nerve in infections with the herpes zoster virus. The major differences in this condition are the presence of small blisters, or vesicles, on the external ear and hearing disturbances, but these findings may occasionally be lacking (zoster sine herpete). Reactivation of existing herpes zoster infection leading to facial paralysis in a Bell's palsy type pattern is known as Ramsay Hunt syndrome type 2. Lyme disease may produce the typical palsy, and may be easily diagnosed by looking for Lymespecific antibodies in the blood or erythema migrans. In endemic areas Lyme disease may be the most common cause of facial palsy. The degree of nerve damage can be assessed using the House-Brackmann score. Because both the nerve to Stapedius and the chorda tympani nerve (taste) are branches of the facial nerve, patients with Bell's palsy may present with hyperacusis or loss of taste sensation in the anterior 2/3 of the tongue. Although defined as a mononeuritis (involving only one nerve), patients diagnosed with Bells palsy may have "myriad neurological symptoms" including "facial tingling, moderate or severe headache/neck pain, memory problems, balance problems, ipsilateral limb paresthesias, ipsilateral limb weakness, and a sense of clumsiness" that are "unexplained by facial nerve dysfunction".[3] This is yet an enigmatic facet of this condition.

[edit] Cause
Some viruses are thought to establish a persistent (or latent) infection without symptoms, e.g., the varicella-zoster virus[4] and Epstein-Barr viruses, both of the herpes family. Reactivation of an existing (dormant) viral infection has been suggested[5] as cause behind the acute Bell's palsy. Studies[6] suggest that this new activation could be preceded by trauma, environmental factors, and metabolic or emotional disorders, thus suggesting that stress - emotional stress, environmental stress (e.g., cold), physical stress (e.g., trauma) - in short, a host of different conditions, may trigger reactivation.

[edit] Pathology

Anatomy of the face. It is thought that as a result of inflammation of the facial nerve, pressure is produced on the nerve where it exits the skull within its bony canal, blocking the transmission of neural signals or damaging the nerve. Patients with facial palsy for which an underlying cause can be found are not considered to have Bell's palsy per se. Possible causes include tumor, meningitis, stroke, diabetes mellitus, head trauma and inflammatory diseases of the cranial nerves (sarcoidosis, brucellosis, etc.). In these conditions, the neurologic findings are rarely restricted to the facial nerve. Babies can be born with facial palsy.[7] In a few cases, bilateral facial palsy has been associated with acute HIV infection.

In some research[8] the herpes simplex virus type 1 (HSV-1) was identified in a majority of cases diagnosed as Bell's palsy. This has given hope for anti-inflammatory and anti-viral drug therapy (prednisone and acyclovir). Other research[5] however, identifies HSV-1 in only 31 cases (18 percent), herpes zoster (zoster sine herpete) in 45 cases (26 percent) in a total of 176 cases clinically diagnosed as Bell's Palsy. That infection with herpes simplex virus should play a major role in cases diagnosed as Bell's palsy therefore remains a hypothesis that requires further research. In addition, the herpes simplex virus type 1 (HSV-1) infection is associated with demyelination of nerves. This nerve damage mechanism is different from the above mentioned - that oedema, swelling and compression of the nerve in the narrow bone canal is responsible for nerve damage. Demyelination may not even be directly caused by the virus, but by an unknown immune system response. The quote below captures this hypothesis and the implication for other types of treatment: It is also possible that HSV-1 replication itself is not responsible for the damage to the facial nerves and that inhibition of HSV-1 replication by acyclovir does not prevent the progression of nerve dysfunction. Because the demyelination of facial nerves caused by HSV-1 reactivation, via an unknown immune response, is implicated in the pathogenesis of HSV-1-induced facial palsy, a new strategy of treatment to inhibit such an immune reaction may be also effective.[5]

[edit] Diagnosis
Bell's palsy is a diagnosis of exclusion; by elimination of other reasonable possibilities. Therefore, by definition, no specific cause can be ascertained. Bell's palsy is commonly referred to as idiopathic or cryptogenic, meaning that it is due to unknown causes. Being a residual diagnostic category, the Bell's Palsy diagnosis likely spans different conditions that our current level of medical knowledge cannot distinguish. This may inject fundamental uncertainty into the discussion below of etiology, treatment options, recovery patterns, etc. See also the section below on Other symptoms. Studies[3] show that a large number of patients (45%) are not referred to a specialist, which suggests that Bells palsy is considered by physicians to be a straightforward diagnosis that is easy to manage. A significant number of cases are misdiagnosed (Ibid.). This is unsurprising from a diagnosis of exclusion, which depends on a thorough investigation.

[edit] Treatment
Bell's palsy affects each individual differently. In patients presenting with incomplete facial palsy, where the prognosis for recovery is very good, treatment may be unnecessary. However, the more severe cases may require treatment. Patients presenting with complete paralysis, marked by an inability to close the eyes and mouth on the involved side, are usually treated, some of them with smile surgery. Early treatment (within 3 days after the onset) is necessary for therapy to be effective.[9] Steroids have been shown to be effective at improving recovery while antivirals have not.

[edit] Steroids
Corticosteroid such as prednisone significantly improves recovery at 6 months and are thus recommended.[10]

[edit] Antivirals
Antivirals (such as acyclovir) are ineffective in improving recovery from Bell's palsy beyond steroids alone.[11] They were however commonly prescribed due to a theoretical link between Bell's palsy and the herpes simplex and varicella zoster virus.[2]

[edit] Surgery
Surgery may be able to improve outcomes in facial nerve palsy that has not recovered.[12] A number of different techniques exist.[12] Smile surgery or smile reconstruction is a surgical procedure that restores the smile for people with facial nerve paralysis.

[edit] Complementary therapy

The efficacy of acupuncture remains unknown because the available studies are of low quality (poor primary study design or inadequate reporting practices).[13]

[edit] Physiotherapy
Physiotherapy can be beneficial to some individuals with Bells palsy as it helps to maintain muscle tone of the affected facial muscles and stimulate the facial nerve.[14] It is important that muscle re-education exercises and soft tissue techniques be implemented prior to recovery in order to help prevent permanent contractures of the paralyzed facial muscles.[14] Muscle reeducation exercises are also useful in restoring normal movement.[15] To reduce pain, heat can be applied to the affected side of the face.[16] In individuals with unresolved facial nerve paralysis, transcutaneous electrical stimulation can be an effective treatment strategy.[17]

[edit] Prognosis
Even without any treatment, Bell's palsy tends to carry a good prognosis. In a 1982 study, when no treatment was available, of 1,011 patients, 85% showed first signs of recovery within 3 weeks after onset. For the other 15%, recovery occurred 36 months later. After a follow-up of at least 1 year or until restoration, complete recovery had occurred in more than two-thirds (71%) of all patients. Recovery was judged moderate in 12% and poor in only 4% of patients.[18] Another study found that incomplete palsies disappear entirely, nearly always in the course of one month. The patients who regain movement within the first two weeks nearly always remit entirely. When remission does not occur until the third week or later, a significantly greater part of the patients develop sequelae.[19] A third study found a better prognosis for young patients, aged below 10 years old, while the patients over 61 years old presented a worse prognosis.[6] Major complications of the condition are chronic loss of taste (ageusia), chronic facial spasm, facial pain and corneal infections. To prevent the latter, the eyes may be protected by covers, or taped shut during sleep and for rest periods, and tear-like eye drops or eye ointments may be recommended, especially for cases with complete paralysis. Where the eye does not close completely, the blink reflex is also affected, and care must be taken to protect the eye from injury. Another complication can occur in case of incomplete or erroneous regeneration of the damaged facial nerve. The nerve can be thought of as a bundle of smaller individual nerve connections that branch out to their proper destinations. During regrowth, nerves are generally able to track the original path to the right destination - but some nerves may sidetrack leading to a condition known as synkinesis. For instance, regrowth of nerves controlling muscles attached to the eye may sidetrack and also regrow connections reaching the muscles of the mouth. In this way, movement of one also affects the other. For example, when the person closes the eye, the corner of the mouth lifts involuntarily. Around 9%[20] of patients have some sort of sequelae after Bell's palsy, typically the synkinesis already discussed, or spasm, contracture, tinnitus and/or hearing loss during facial movement or crocodile tear syndrome. This is also called gustatolacrimal reflex or Bogorads Syndrome and involves the sufferer shedding tears while eating. This is thought to be due to faulty regeneration of the facial nerve, a branch of which controls the lacrimal and salivary glands. Gustatorial sweating can also occur.

[edit] Epidemiology
The annual incidence of Bell's palsy is about 20 per 100,000 population, and the incidence increases with age.[21] Bells palsy affects about 40,000 people in the United States every year. It affects approximately 1 person in 65 during a lifetime.[citation needed] Familial inheritance has been found in 414% of cases.[22] Bell's Palsy is three times more likely to strike pregnant women than non-pregnant women.[23] It is also considered to be four times more likely to occur in diabetics than the general population.[24] A range of annual incidence rates have been reported in the literature: 15,[22] 24,[25] and 25-53[3] (all rates per 100,000 population per year). Bells palsy is not a reportable disease, and there are no established registries for patients with this diagnosis, which complicates precise estimation.

[edit] History

This lesion was described by Sir Charles Bell, a Scottish surgeon. In 1829 he presented three cases at the Royal Society of London. Two cases were idiopathic and the third was due to a tumour of the parotid gland.