Bell's Palsy

Bell's palsy is a weakness of the facial muscles. It develops suddenly, and the cause is not known.
Most people make a full recovery within 2-3 months. You should protect your eye if you cannot
close your eyelid fully.

What is Bell's palsy?

Bell's palsy is a weakness (paralysis) that affects the muscles of the face. It is due to a problem with the facial
nerve. It usually affects one side of the face, but rarely both sides are affected. Bell's palsy is named after the
doctor who first described it.

What is the facial nerve?

You have a facial nerve (also called the seventh cranial nerve)
on each side of your face. Each facial nerve comes out from
your brain, through a small tunnel in your skull just under your
ear.
The nerve splits into many branches that supply the small
muscles of the face that you use to smile, frown, etc. It also
supplies the muscles that you use to close your eyelids.
The facial nerve also takes taste sensations from your tongue
to your brain.

Who gets Bell's palsy?

Anyone can get Bells palsy, and it affects both men and women equally. It most commonly occurs between the
ages of 10 and 40. Bell's palsy is the most common cause of a sudden facial weakness. About 1 in 70 people
have a Bell's palsy at some stage in their life.

What causes Bell's palsy?

The exact cause is not known. It is thought that inflammation develops around the facial nerve as it passes
through the skull from the brain. The inflammation may compress (squash) the nerve as it passes through the
skull. The nerve then partly, or fully stops working until the inflammation goes. If the nerve stops working, the
muscles that the nerve supplies also stop working.
The cause of the inflammation is not known, but it is probably due to a viral infection. There is some evidence
that the cold sore virus (herpes simplex virus) causes most cases of Bell's palsy.
(Note: The term Bell's palsy is given for a facial palsy 'of unknown cause'. Rarely, facial palsy is caused by a
head injury, sarcoidosis, Lyme disease, and other rare problems. These are not called Bell's palsy as there is a
known underlying cause, and you would normally have other symptoms too. Also, some people who have a
stroke develop facial weakness. This is different to the facial weakness of Bell's palsy.)

What are the symptoms of Bell's palsy?

Weakness of the face which is usually one sided. The weakness usually develops quickly, over a few
hours or so. You may first notice the weakness after getting up in the morning, and so it may appear
quite dramatic. It may gradually become worse over several days. The effects of the weakness vary,
depending on whether the nerve is partially or fully affected. These include the following.
o Your face may droop to one side. When you smile, only half of your face may move.
o Chewing food on the affected side may be a problem. Food may get trapped between your gum
and cheek. Drinks and saliva may escape from the side of your mouth.
o You may not be able to close an eye fully. This may result in a watery or dry eye.
o You may not be able to wrinkle your forehead, whistle, or blow out your cheek.
Most cases are painless, but an ache near the ear may occur for a few days.

Loud sounds may be uncomfortable and normal noises may sound louder than usual. This is
because a tiny muscle in the ear may stop working.
Your may lose the sense of taste on the side of the tongue that is affected.

Does Bell's palsy affect the brain or other parts of the body?
No. Bells palsy is a local problem confined to the facial nerve and facial muscles. If you have other symptoms,
such as weakness or numbness in other parts of your body, there will be another cause and you should tell
your doctor.

How does Bell's palsy progress?

Without treatment, full recovery occurs in about 8 in 10 cases. The function of the nerve gradually returns to
normal. Symptoms usually start to improve after about 2-3 weeks, and have usually gone within two months. In
some cases, it can take up to twelve months to fully recover.
In about 2 in 10 cases, symptoms do not completely go. Some weakness may remain for good. However, it is
often a slight weakness of part of the face. It is rare to have no improvement at all.

What is the treatment for Bell's palsy?

Steroid tablets may be prescribed for one or two weeks. Steroids help to reduce inflammation. But, steroid
treatment for Bell's palsy is controversial. As mentioned above, you are likely to recover fully without any
treatment, and some studies suggest that steroids make no difference to the outcome. However, some doctors
believe that a course of steroids may help to increase your chance of full recovery even more. If steroids are
advised, you should start them as soon as possible after the onset of symptoms.
Eye protection. If you cannot close your eyelids fully, the front of your eye is at risk of becoming damaged.
Your doctor may advise one or more of the following until the eyelids recover.

Wear an eye pad or goggles to protect the eye.

Eye drops may help to lubricate the eye.

Eye ointment may be better at bedtime to lubricate the eye overnight.

An option is to tape the upper and lower lid together.

Surgery to the face may be an option for the small number of cases where the facial weakness does not
recover, and remains unsightly.

Will it happen again?

In most cases, a Bell's palsy is a 'one-off'. About 1 in 10 people who have a Bell's palsy have a further episode
sometime in the future, often several years afterwards.
EMIS and PIP 2004 Updated: May 2002 CHIQ Accredited

Bell's Palsy
WhatisBell'spalsy?
Bell'spalsyisaneurologicaldisorderthatcausesweaknessor
paralysisononesideoftheface.Itiscausedbydamagetothefacial
cranialnervethenervethatcontrolssomeofthefacialmuscles,as
wellassomeofthetastebudsandglandsinthemouth.Bell'spalsy
usuallygoesawayonitsowninafewweeksormonthsandalmost
Bell's Palsy patients

neverlastsformorethanayear.Recurrenceofthedisordermay
happen,althoughin90%ofallcasesitisaonceinalifetime
condition.
Bell'spalsyaffectspeopleofanyage,althoughpatientsaremost
commonlybetweentheagesof20to35.Pregnantwomen,diabetics,
andpeoplewithandupperrespiratoryinfection,suchasthefluora
cold,areallatagreaterriskfordevelopingBell'spalsy.Manythings
cantriggerBell'spalsy,thoughsomepublichealthexpertssuspect
thatmostcasesofBell'spalsyarecausedbythevirusthatcauses
commoncoldsores(herpessimplex).
Cause:
Anumberofthingscandamagethefacialcranialnerveandleadto
Bell'spalsy,includingvariousviralinfectionssuchasherpes,Lyme
disease,mumps,tuberculosis,orHIV.Otherpossiblecausesinclude
traumaassociatedwithtumors,bonyabnormalities,askullfractureor
surgery;neurologicaldysfunctioncausedbydiabetes;orvarious
neurologicaldisorderssuchasGuillainBarresyndrome.Usually
whenapersonisdiagnosedwithBell'spalsy,asopposedtoGuillain
Barresyndrome,myastheniagravisorsomeotherconditionthat
causesfacialparalysis,theunderlyingcauseisnotknownandisoften
relatedtoaviralinfection.
Symptoms:
The7thcranialnervehasbothmotorandsensoryfunctions.Itsmotor
functionsincludeshuttingtheeye,liftingtheeyebrow,andthe
musclesthatmovethemouthandlips;itssensoryfunctionsinclude

Superior semicircular canal and the petrous

portion of the facial (VII) nerve as it enters
the internal auditory canal. This is the narrowest
part of the facial nerve and the segment
which is felt to be damaged in Bell's Palsy

Anatomy of peripheral taste pathways. Multiple

nerves, including cranial nerves VII, IX and X,
transmit taste information from the mouth and
pharynx to the brain via the brain stem.

tastingonthefrontofthetongueanddampeningthelevelofthe
soundwehear.SothesymptomsofBell'spalsyincludeany
abnormalitiesinvolvingthesevariousfacialmuscles,theabilityto
tasteaswellashyperacusis(hearingsoundsveryloud)onthe
affectedside.Additionally,manypeopledescribefeelingapain
behindtheirearornearthejawafewdaysbeforetheothersymptoms
develop.

MotorMovementoftheFace
ThemostcommonsymptomofBell'spalsyisweaknesson
oneentiresideoftheface.Apersonmaynotbeabletoclose
oneeye,ortheymayhavedifficultyshuttingtheireye
completely.SometimespeoplewithBell'spalsygeteye
injuriesasaresultoftheeyenotshuttingcompletelyin
defense.Theforeheaddoesn'twrinklewhenapersontriesto
lifttheireyebrow.Thelowerpartofthefacemaydropdown.
Patientsaren'tabletolifttheirmouthstosmileorfilltheir
cheekswithair.Theymaydroolfromthemouth.Some
peoplemayfeelatinglingornumbnessintheface.
SensoryFunctions
Somepeoplemaynotbeabletotasteonthefrontoftheir
tongue.Peoplemayhaveanincreasedsensitivitytosoundin
theearontheaffectedside,andsothingssoundlouderthan
normal.

Diagnosis:
UsuallyBell'sPalsyisprobablyduetothebody'sresponsetoavirus:

The anatomy of the cranial nerves VII

(facial nerve) on the face.

The anatomy of the cranial nerves VII

(facial nerve) on the face.

inreactiontothevirusthefacialnervewithintheear(temporal)bone
swells,andthispressureonthenerveinthebonycanaldamagesit.In
ordertobesurethatthisisthecauseofthefacialweakness,andnot
somethingelse,aspecialsetofquestionswillbeasked.Afteran
examinationofthehead,neck,andears,aseriesoftestsmaybe
performed.
Themostcommontestsare:

HearingTest:
Determinesifthecauseofdamagetothenervehasinvolved
thehearingnerve,innerear,ordelicatehearingmechanism.

BalanceTest:
Evaluatesbalancenerveinvolvement.

TearTest:
Measurestheeye'sabilitytoproducetears.Eyedropsmaybe
necessarytopreventdryingofthesurfaceoftheeyecornea).

Imaging:
CT(computerizedtomography)orMRI(magneticresonance
imaging)determineifthereisinfection,tumor,bonefracture,
orotherabnormalityintheareaofthefacialnerve.

ElectricalTest:
Stimulatesthefacialnervetoassesshowbadlythenerveis
damaged.Thistestmayhavetoberepeatedatfrequent

intervalstoseeifthediseaseisprogressing.
Inaclinicalexamdiagnosis,usuallythedoctormayaskthepatients
toliftyoureyebrowsandthenlowerthem;ifthetwoeyebrowsdon't
moveinthesameway,itsuggeststhatonesideisweakerthanthe
other.Similarly,ifoneeyedoesn'tclosetightly,itsuggeststhatthe
musclescontrollingitareweakened.Notbeingabletotasteonthe
frontofthetongueandnoisessoundinglouderthanexpectedareboth
indicationsofBell'spalsy.SymptomsofBell'spalsywillappearonly
inthefacemuscleweaknessinotherpartsofthebodysuggeststhat
thereissomeotherproblem.
InImagingtest,thepatientsmaybenecessarytoundergoaCT
(computerizedaxialtomography)orMRI(magneticresonance
imaging)toruleoutotherneurologicaldisordersinBell'sPalsy.For
example,itmaybenecessarytoruleoutbothtumorsandstrokes,
whichalsocancausefacialparalysis.Moreover,laboratoryorblood
studiesmaybenecessarytodeterminetheunderlyingcause.
Treatment:
UnfortunatelythereisnospecifictreatmentforBell'spalsy.Italmost
alwayseventuallygoesawayonitsownwithoutanysortof
intervention.Almost90%ofallpatientsrecovercompletely.Most
peoplerecoverwithinafewweeks,thoughsomecasespersistfor
severalmonths.Only1in10patientsneverexperienceacomplete
disappearanceofsymptoms.
Ineyetreatment,thepatientshouldkeeptheeyeshealthyandmoist.
Oneofthepurposesofblinkingandclosingtheeyesistokeepthe

eyeswet.Ifapersoncan'tclosetheireyes,becausethemusclesthat
controltheeyelidsareparalyzed,itisimportanttokeeptheeyes
moistandpreventitchinganddiscomfort.Eyedropsareprescribed
fortheday,aneyeointmentfornight,andpatientsshouldsleepwith
ahumidifierormoisturechamberatnight.Patientsshouldwearan
eyepatchforprotection.
Acorticosteroiddrugcanbeadministeredtorelieveswellingand
mayinsomecasespreventanearlyconditionfromgettingworse.
Themostcommoncorticosteroidusedisprednisone.Itisusually
givenforoneweek,thoughitshouldn'tbeprescribedifthereareany
signsofinfectionorotherproblemsthatareknowntocause
complicationswithshorttermsteroiduse.Apainrelievermaybe
necessarytorelievepain.Sometimesphysicaltherapycanbehelpful
instrengtheningthefacialmuscles.

Facial nerve palsy

Mild left facial nerve palsy. Note the

slightly drooping of the corner of the
left lip.

Getting the patient to smile reveals

Getting the patient to forcibly shut her
asymmetry of the action of the facial eyes. The left lashes are not buried due
muscles.
to the decreased tone of orbicularis oculi.

The Facial Nerve

The cranial nerve injured in Bell's Palsy is CN-VII (7th
cranial nerve). It originates in an area of the brain stem
known as the Pons. The 7th nerve passes through the
stylomastoid foramen and enters the parotid gland. It divides
into its main branches inside the parotid gland. These
branches then further divide into 7000 smaller nerve fibers
that reach into the
face, neck, salivary
glands and the outer
ear. The nerve
controls the
muscles of the neck,
the forehead
and facial

expressions, as well as perceived sound volume. It also stimulates secretions of the lower jaw, the tear glands
and the salivary glands in the front of the mouth. Taste sensations at the front 2/3 of the tongue and sensations at
the outer ear are transmitted by the 7th nerve.
Bells Palsy is caused by an inflammation within a small bony tube called the fallopian canal. The canal is an
extremely narrow area. An inflammation within it is likely to exert pressure on the nerve, compressing it.
Likewise, if the nerve itself becomes inflamed within this small canal, it can encounter pressure, with the same
result of compression. The nerve has not yet exited the skull and divided into its several branches, resulting in
impairment of all functions controlled by the 7th nerve. If only part of the face is affected, the condition is not
Bell's palsy. (See Comparison of Bells and Stroke) If, for example, the mouth area is weak but the forehead
moves, Bells palsy is ruled out. Trauma induced by tumor, surgery, etc. can occur at a location where the nerve
has already divided into its main branches. This type of trauma may spare one or more branches and allow some
muscles to remain functional.

FIGURE LEGEND
1. Facial nerve nucleus
2. Trigeminal nerve: Spinal nucleus
3. Superior salivary nucleus
4. Solitary tract
5. Porus acusticus internus
6. Meatal foramen
7. Greater petrosal nerve
8. Sphenopalatine ganglion
9. Maxillary nerve
10. Lacrimal gland
11. Deep petrosal nerve
12. Vidian nerve
13. Nerve to glands of nose and palate
(motor fibers to levator palati muscles)
14.Minor petrosal nerve anastamosis
15. Stapedial nerve
16. Chorda tympani
17. Auricular branch
18. Stylomastoid foramen
19. Lingual nerve
20. Submandibular ganglion
21. Submandibular gland
22. Sublingual gland

Region of the Facial Nerve

The facial nerve takes an interesting course from both a teleological as well as an anatomic
perspective. Anatomically the course of the facial nerve is fascinating for its long canal in the
petrous temporal bone (above right) alongside the labyrinth.

Facial Nerve Anatomy:

http://www.neuro.wustl.edu/neuromuscular/pathol/diagrams/viianat.htm

from fifth nerve involvement (Fovilles syndrome)

Questions:
1. How can you determine the level of lower facial nerve palsy?
Answer:
The following tests of the autonomic functions are useful:
Dry eye on the same side (damage proximal to the greater petrosal nerve)
Taste sensation on the anterior 2/3 of the tongue (damage proximal to the chorda tympani)
2. What is crocodile tear?
Answer:
The lacrimation which occurs during chewing. It is caused by misdirection of the facial nerve during
reinnervation ie. The nerve fibres which originally supply the mandibular and sublingual glands
reinnervate the lacrimal gland through the greater petrosal nerve. As a result during chewing the lacrimal
gland becomes stimulater rather than the salivary glands.
3. what is Merkelsson-Rosenthals Syndrome ?
Answer:
This is a condition of unknown aetiology with an onset in childhood or adolescence. There are recurrent
facial paralysis (which may be unilateral or bilateral) with marked facial swelling and furrowing of the
tongue (lingua plicata)