Bell's Palsy

Question 1

What nerve is affected?

Onset?

Bi/unilateral?

You get some numbness or pain around the ear. Do you get this with on the ipsilateral or contralateral side?

Answer 1

Facial nerve

Rapid - overnight/after a nap - peaks around 24-72 hrs

Unilateral facial weakness

Ipsilateral

Question 2

What muscle in the ear may be impaired and what will this lead to?

What other sensory component is affected? - think about CN VII function?

Answer 2

Stapedius palsy - hypersensitivity to sound

Taste - anterior 2/3 of tongue is affected but sometimes the patient might not notice it.

Question 3

What will you notice on examination?

You also get failure of eye closure. What might this cause?

Answer 3

The patient will be unable to wrinkle their forehead - which confirms a LMN lesion pathology.

Unilateral sagging of the mouth
Drooling of saliva
Food trapped between gum and cheek
Speech difficulty

Watery eyes
Dry eyes
Ectropion - sagging and turning-out of the lower lid
Injury of foreign bodies

Question 4

What differentials may cause bilateral weakness?

Answer 4

Lyme disease
Gillian-Barre
Sarcoid
Trauma

Question 5

Investigations:
Bloods:

ESR can be done for inflammation and glucose for hypoglycaemia.

What does raised Borrelia antibodies indicate?

What does raised VZV antibodies to indicate?

What do you do to look for space-occupying lesions, stroke and MS?

Answer 5

Lyme disease

Ramsey-Hunt Syndrome

CT/MRI

Question 6

Management:

Drugs - what, if given before 72 hrs of onset, could speed recovery?

How can the eye be protected since blinking is affected?

Surgery may be needed for:

• Lagophthalmos - what is it?
• Severe ectropion - what is it?

Answer 6

Prednisolone

Dark glasses
Artificial tears (e.g. hypromellose) if drying
Encourage regular eyelid closure by pulling down the lid by hand
Use tape to close it at night

The inability to close the eyelids completely.
Sagging and turning-out of the lower lid.

Question 7

Ramsey-Hunt Syndrome:

What is it?

Symptoms?

How is it diagnosed?

Rx?

Answer 7

A latent VZV reactivating in the ganglion of CN VII.

Painful vesicular rash on auditory canal +/- on drum, pinna, tongue, palate or iris
+
ALL THE THINGS YOU GET IN BELL’S PALSY

Clinical - antiviral Rx thought to be most effective within the first 72 hrs, while the virus is still replicating.

Antiviral
Prednisolone