Neurology · Year 3 · from Neurology
Case 1: Bell's Palsy
Patient Demographics
- Age: 38 years
- Sex: Female
- Occupation: Marketing manager
Chief Complaint
"I woke up and couldn't move the left side of my face."
History of Present Illness
The patient woke up this morning and noticed her face felt "different." When she looked in the mirror, she was alarmed to see that the left side of her face was drooping. She cannot close her left eye completely, cannot smile on the left side, and food falls out of the left side of her mouth when eating. She noticed some pain behind her left ear yesterday evening, which she attributed to sleeping in an awkward position. She also reports that sounds seem unusually loud in her left ear (hyperacusis) and that food tastes "strange" on the left side of her tongue. No hearing loss, no vertigo, no other weakness or numbness. She had a viral upper respiratory infection about 2 weeks ago. She has no history of diabetes, no rash, no recent travel, and no tick exposure.
Neurological Examination Findings
Mental Status:
- Alert, oriented, anxious about facial appearance
- Speech: Slightly slurred due to facial weakness
Cranial Nerves:
CN VII (Facial) - LEFT SIDE:
- Complete left facial paralysis affecting ENTIRE hemiface
- Forehead: Cannot wrinkle forehead or raise eyebrow on left
- Eye: Cannot close left eye completely (Bell's phenomenon present - eye rolls up on attempted closure)
- Mouth: Cannot smile, show teeth, or puff cheek on left
- Nasolabial fold flattened
- Mouth droops to left at rest
- Taste: Decreased on anterior 2/3 of tongue on left (chorda tympani)
- Hyperacusis on left (stapedius involvement)
Other Cranial Nerves:
- CN I: Intact
- CN II: Visual acuity 20/20 OU, visual fields full, pupils equal and reactive, no papilledema
- CN III, IV, VI: Extraocular movements full, no ptosis, no diplopia
- CN V: Facial sensation intact, corneal reflex present (sensory intact, motor impaired on left due to VII)
- CN VIII: Hearing grossly intact bilaterally by finger rub, no nystagmus
- CN IX, X: Palate elevates symmetrically, gag intact
- CN XI: Trapezius and SCM 5/5 bilaterally
- CN XII: Tongue midline, no atrophy
Motor, Sensory, Reflexes:
- All within normal limits
- No other weakness
- Normal gait
Skin Examination:
- No vesicular rash in or around ear (ruling out Ramsay Hunt syndrome)
- No erythema migrans (ruling out Lyme disease)
Key Clinical Features
- Peripheral facial weakness - entire hemiface involved including forehead
- Sudden onset - developed overnight
- Associated features: Hyperacusis (stapedius), taste changes (chorda tympani), retroauricular pain
- No other cranial nerve involvement
- No rash - distinguishes from Ramsay Hunt syndrome
Central vs Peripheral Facial Weakness
| Feature | Bell's Palsy (Peripheral) | Stroke (Central) |
|---|---|---|
| Forehead | Affected - cannot raise eyebrow | Spared - can raise eyebrow |
| Eye closure | Incomplete | Usually preserved |
| Taste | May be affected | Not affected |
| Hyperacusis | May be present | Absent |
| Other deficits | Isolated facial weakness | Often hemiparesis, aphasia |
Diagnosis
Bell's Palsy (Idiopathic Peripheral Facial Nerve Palsy)
- Diagnosis of exclusion
- Likely related to HSV-1 reactivation in geniculate ganglion
House-Brackmann Grading
- Grade IV (Moderately Severe): Obvious weakness, incomplete eye closure, asymmetric mouth movement
Management
Pharmacological Treatment (started within 72 hours - ideal):
- Prednisone 60-80 mg daily for 7 days (or taper over 10 days)
- Strong evidence for improved recovery
- Started immediately in this patient
- Valacyclovir 1000 mg TID for 7 days (optional, consider for severe cases)
- Evidence less robust than steroids
- May provide modest additional benefit in severe/complete paralysis
- Added in this patient due to complete paralysis
Eye Protection (CRITICAL):
- Artificial tears - apply every 2 hours while awake
- Lubricating eye ointment - apply at bedtime
- Moisture chamber or tape - tape eyelid closed at night
- Sunglasses - protect from debris and wind
- Ophthalmology referral if unable to close eye or corneal symptoms
Patient Education:
- Prognosis: ~85% will recover completely
- Recovery typically begins within 3 weeks, complete by 6 months
- Return immediately if: New weakness elsewhere, rash appears, hearing loss
- Avoid driving if unable to close eye (impaired peripheral vision)
Follow-up:
- Re-evaluate in 1 week
- Consider EMG/nerve conduction studies if no improvement by 3 weeks
- Refer to facial nerve specialist if no recovery by 6 months
Prognosis
Favorable factors in this patient:
- Young age
- No diabetes
- Incomplete paralysis initially not present (but developed)
- Early treatment
Expected outcome: Good - 85% of Bell's palsy patients recover fully or nearly fully
Potential Complications to Monitor
- Corneal abrasion/ulceration - from incomplete eye closure
- Synkinesis - aberrant regeneration causing involuntary movements
- Crocodile tears - gustatory-lacrimal reflex (eating causes tearing)
- Persistent weakness - in 15% of patients
Clinical Image
Image Description: Clinical photograph demonstrating left peripheral facial nerve palsy (Bell's palsy). Note the drooping of the left side of the face, inability to fully close the left eye, and asymmetric smile affecting the entire left hemiface including the forehead.
Attribution: Image from Wikimedia Commons. Licensed under CC BY-SA 3.0. Source: https://commons.wikimedia.org/wiki/File:Bell%27s_Palsy.png