Bells palsy & ramsay hunt syndrome

Question 1

What are the general symptoms of facial palsys (from any cause) ?

Answer 1

• Unilateral sagging of the mouth, which is drawn upwards on the normal side on smiling causing a grimace
• Drooling of salvia
• Food trapped between gum and cheek
• Speech difficulty
• Failure of eye closure may cause a watery or dry eye

Question 2

What distinguishes bells palsy from other causes of facial palsy ?

Answer 2

• Abrupt onset of symptoms e.g. overnight or after a nap, with complete unilateral facial weakness at 24-72hrs
• Ipsilateral numbness or pain around the ear
• Decreaed taste (ageusia)
• Hypersensitivity to sounds

Other pathologies causing facial palsy may be indicated by bilateral signs, UMN signs, other cranial neuropathies present along with facial palsy e.g. CN V

Limb weakness

Rashes

Question 3

What is the key sign to differentiate between a bells palsy and a UMN lesion causing facial palsy ?

Answer 3

Get patient to wrinkle forehead and close eyes forcefully, in an UMN lesion they are still able to do this whereas they are not in bells palsy

This is because this area of the face is under bilateral cortical control

Question 4

What are the main causes of facial palsys ?

Answer 4

• Bells palsy - 70% of cases
• Ramsay hunt syndrome
• Lyme disease
• Meningitis
• Stroke, tumours, MS
• DM, sarcoidosis, GBS

Question 5

What tests should be arranged for someone presenting with facial palsy ?

Answer 5

• Check - ESR, glucose, borrelia antibodies (these will be increased in lymes disease which is indistuginshable from bells palsy clinically)
• Check VSV antibodies which will be increased in ramsay hunt syndrome
• MRI for SOL’s, stroke, MS

Question 6

What is the management of bells palsy ?

Answer 6

• If given within 72hrs of onset - prednisolone speeds recovery
• Also may use dark glasses & artificial tears to protect the eyes
• Encourage regular closing of the eyelid by hand and use tape to close the eyes at night

Question 7

What is the classic presentation of ramsay hunt syndrome ?

Answer 7

• Painful vesicular rash on the auditory canal (herpes zoster oticus) +/- on the drum, pinna, tongue palate or iris
• Causes ipsilateral facial palsy
• Loss of taste
• Vertigo
• Tinnitus
• Deafness, dry mouth and eyes

Question 8

What is the treatment of ramsay hunt syndrome ?

Answer 8

Antivirals - aciclovir + prednisolone