Sir Charles Bell
Bell’s Palsy Diagnosis and Treatment:
The number one cause of facial paralysis in the United States is Bell’s palsy. Bell’s palsy was first discovered by Sir Charles Bell, a prominent physician, and its terminology has been confused with facial paralysis ever since. Not all patients who have facial paralysis have Bell’s palsy. Bell’s palsy is coined for any type of facial paralysis that does not have any other associated causes such as tumors, trauma and salivary gland inflammation.
Recent research has shown that Bell’s palsy occurs when a virus (herpes simplex virus, HSV) gets reactivated in the bone behind the ear (temporal bone.) When the nerve gets reactivated and swollen, it ends up causing the nerve to essentially “shut down.” This occurs in a very rapid manner and most patients who have Bell’s palsy present have acute onset and immediate facial paralysis. Other symptoms of Bell’s palsy may include an aura that precedes it or a sensation that your face movement may be inhibited.
Patients who have Bell’s palsy should go to the emergency room immediately and get evaluated. The typical studies that need to be performed depending on the physician evaluation include laboratory testing for Lyme disease, thyroid function test, HIV and hepatitis. A complete neurologic and ear, nose, and throat evaluation needs to be done. If there are any questions, an ENT specialist or a facial nerve expert needs to be consulted to make sure that there is no other cause of the facial paralysis other than the Bell’s palsy. Occasionally, a tearing test function, computed tomography (CT scan) and magnetic resonance imaging (MRI) exam may need to be done to rule out other causes of facial paralysis. An electromyography or electroneurography (ENoG) may need to be performed in patients with severe cases of facial paralysis who are believed to have Bell’s palsy. Many physicians and internists do not have significant knowledge about facial paralysis and Bell’s palsy and hence may not perform adequate tests. So please make sure that you are evaluated at some point within that first three weeks by a facial never expert or an ear, nose and throat specialist.
Please contact the Facial Paralysis Institute on the right hand side of this page if you have any further questions about finding a specialist in your area.
Examination and tests to be performed:
- A complete ear, nose and throat evaluation to make sure that there is no inner ear infection, there is no associated dizziness, there is no evidence of any head and neck tumor or malignancy.
- A complete neurologic evaluation.
- Hearing test to see if there is any damage to the hearing or inner ear issues.
- Vestibular test to make sure that the nerve balance is intact.
- Tearing test to evaluate the level of tearing function as that could be involved with a tumor.
- A CT scan of the neck and temporal bone to rule out any tumors or trauma to the area.
- An MRI examination of the internal auditory canal and brain to rule out any tumors such as acoustic neuroma.
- An electrophysiologic test such as ENoG and EMG.
Incidence and Prevalence
The risk factors for Bell’s palsy are not completely understood, but the chances of obtaining or having Bell’s palsy in one’s life may be one in 64 individuals. It is more commonly seen in patients who are pregnant have a family member with Bell’s palsy, have had previous Bell’s palsy as well as patients of Japanese ancestry. Other risk factors for patients with facial paralysis not necessarily related to Bell’s palsy include Lyme disease, typhoid fever, Guillain-Barré syndrome, trauma, temporal bone fracture, tumors including acoustic neuroma and other types of viruses. Again, it is extremely important to differentiate Bell’s palsy and facial paralysis. Facial paralysis is a general term given to all patients who have weakness of their face including patients with Bell’s palsy. Bell’s palsy is a subset of patients who have facial paralysis that is a resultant of a virus reactivation from herpes simplex virus.
Patients who develop Bell’s palsy fall into three groups: The first group, which includes 85% of individuals who have Bell’s palsy completely recover from the Bell’s palsy with no noticeable deformity or issue. 10% of individuals have incomplete recovery with synkinesis and partial facial weakness. 5% of the patients have complete facial paralysis and significant synkinesis. In this 5% of individuals extreme care must be made to make sure that there is not a missing tumor or other causes that may not be related to Bell’s palsy. Individuals who have risks factors that may increase the chance of having a worst outcome include: not having medical treatment immediately after the onset of Bell’s palsy, pregnancy, and presenting with severe facial paralysis.
The treatment of Bell’s palsy is varied depending on the time and presentation. If someone develops facial paralysis they need to immediately be evaluated and other causes of facial paralysis such as tumor, trauma, and inner ear infection must be ruled out. Once all other causes of facial paralysis have been ruled out, then the patient is given the diagnosis of Bell’s palsy. For Bell’s palsy the patient needs to be treated immediately with high dose steroids (prednisone) as well as antiviral medications (Famvir, Valtrex.) It is imperative that these medications get started immediately. In patients who are pregnant and present with Bell’s palsy caution should be made and this decision should be made in consultation with your OB/GYN. If the patients have presented with complete and total paralysis then further studies need to be performed and other immediate surgical treatments may be warranted depending on the expertise in your area. At the Facial Paralysis Institute for patients who have complete facial paralysis upon presentation we do recommend obtaining an EMG/ENoG testing in addition to CT scan and MRI. If the ENoG reveals significant dysfunction of the facial nerve then one of our neuro-otologists will evaluate the patient to see if they are candidates for facial nerve decompression, which may help in reducing the long-term sequelae of facial paralysis. Once the immediate treatment has been initiated, careful follow up with a facial nerve paralysis expert needs to be continued for the first year of treatment. Other issues that needs to be immediately attended to include eye protection. Patients who have total facial paralysis may have an inability to close their eyes completely (lagophthalmos). Patients who present with an inability to close their eyes are at a high risk of developing ulcerations and injury to their cornea.
For patients with facial paralysis and/or synkinesis who are unable to effectively smile, selective neurolysis is the most advanced treatment available. Selective neurolysis is a surgical procedure that involves the surgeon releasing the platysma muscle (the muscle that pulls the mouth downward) and decreasing nerve activity in the nerves that counteract the smile mechanism so that the mouth can once again turn upward, restoring the patient’s ability to smile.
Supercharging and Signal Upgrading of Facial Nerve
Patients who have partial paralysis either from Bell's Palsy or other etiologies such as acoustic neuroma or temporal bone fractures may also be candidates for "supercharging" or "signal upgrading" procedure in order to increase the power of the facial nerve and help the facial muscles work more effectively. The concept is to help strengthen weak smile muscles while preserving basic function. The masseteric nerve is the most common nerve utilized to help strengthen the facial nerve. The procedure is an outpatient procedure.
Botox for Bell's Palsy
Botox is one of the most effective treatments for patients with bell's palsy, partial facial paralysis and synkinesis. The neuromodulator relaxes the hyperactive muscles and can temporarily restore some facial symmetry and improve appearance. Please read our report/press release on Botox and it's effects in Bell's Palsy treatment to learn more.
Below is an image of a Bell's palsy patient before and after Botox for Bell's palsy treatment with Dr. Azizzadeh.
If you are suffering from Bell’s palsy, schedule a consultation with Dr. Azizzadeh by calling 310.657.2203 today!
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BABAK AZIZZADEH, MD FACS
Director, The Facial Paralysis Institute - Associate Clinical Professor - Facial Plastic & Reconstructive Surgery David Geffen School of Medicine at UCLA
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