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HistoryThe diagnosis of Bell palsy must be made on the basis of a thorough history and physical examination, as well as the use of diagnostic testing when necessary. Bell palsy is a diagnosis of exclusion. Clinical features of the disorder that may help to distinguish it from other causes of facial paralysis include the sudden onset of unilateral facial paralysis and the absence of signs and symptoms of CNS, ear, and cerebellopontine angle disease. Symptoms of Bell palsy include the following:
Early symptoms include the following:
OnsetThe onset of Bell palsy is typically sudden, and symptoms tend to peak in less than 48 hours. This sudden onset can be frightening for patients, who often fear they have had a stroke or have a tumor and that the distortion of their facial appearance will be permanent. Because the condition appears so rapidly, patients with Bell palsy frequently present to the emergency department (ED) before seeing any other health care professional. More people first notice paresis in the morning. Because the symptoms require several hours to become evident, most cases of paresis likely begin during sleep. Facial paralysisThe paralysis must include the forehead and lower aspect of the face. The patient may report the inability to close the eye or smile on the affected side. He or she also may report increased salivation on the side of the paralysis. If the paralysis involves only the lower portion of the face, a central cause should be suspected (ie, supranuclear). If the patient complains of contralateral weakness or diplopia in conjunction with the supranuclear facial palsy, a stroke or intracerebral lesion should be strongly suspected. If a patient has gradual onset of facial paralysis, weakness of the contralateral side, or a history of trauma or infection, other causes of facial paralysis must be strongly considered. Progression of the paresis is possible, but it usually does not progress beyond 7–10 days. A progression beyond this point suggests a different diagnosis. Patients who have bilateral facial palsy must be evaluated for Guillain-Barré syndrome, Lyme disease, and meningitis. Many patients report numbness on the side of the paralysis. Some authors believe that this is secondary to involvement of the trigeminal nerve, whereas other authors argue that this symptom is probably from lack of mobility of the facial muscles and not lack of sensation. Ocular manifestationsEarly ocular complications include the following:
Late ocular manifestations include the following:
Two thirds of patients complain about tear flow. [9] This results from the reduced function of the orbicularis oculi in transporting the tears. Fewer tears arrive at the lacrimal sac, and overflow occurs. The production of tears is not accelerated. Posterior auricular painHalf of the patients affected with Bell palsy may complain of posterior auricular pain. [9] The pain frequently occurs simultaneously with the paresis, but pain precedes the paresis by 2–3 days in about 25% of patients. Ask the patient if he or she has experienced trauma, which may account for the pain and facial paralysis. One third of patients may experience hyperacusis in the ear ipsilateral to the paralysis, which is secondary to weakness of the stapedius muscle. Taste disordersWhile only one third of patients report taste disorders, [9] 80% of patients show a reduced sense of taste. Patients may fail to note reduced taste, because of normal sensation in the uninvolved side of the tongue. Early recovery of the sense of taste suggests that the patient will experience a complete recovery. Facial spasmFacial spasm, a very rare complication of Bell palsy, occurs as tonic contraction of 1 side of the face. Spasms are more likely to occur during times of stress or fatigue and may be present during sleep. This condition may occur secondary to compression of the root of the seventh nerve by an aberrant blood vessel, tumor, or demyelination of the nerve root. Facial spasm occurs most commonly in patients in the fifth and sixth decades of life. Sometimes the etiology is not found. The presence of progressive facial hemispasm with other cranial nerve findings indicates the possibility of a brainstem lesion. Synkinesis is an abnormal contracture of the facial muscles while smiling or closing the eyes. It may be mild and result in slight movement of the mouth or chin when the patient blinks or in eye closure with smiling. Crocodile tears can be observed; patients shed tears while they eat. Cranial neuropathiesSome believe that other cranial neuropathies may also be present in Bell palsy; however, this is not uniformly accepted. The symptoms in question include the following:
 Physical ExaminationWeakness and/or paralysis from involvement of the facial nerve affects the entire face (upper and lower) on the affected side. A careful examination of the head, ears, eyes, nose, and throat must be carried out in all patients with facial paralysis. Time must also be taken to examine the patient’s skin for signs of squamous cell carcinoma, which can invade the facial nerve, and parotid gland disease. Focus attention on the voluntary movement of the upper part of the face on the affected side; in supranuclear lesions, such as occur in a cortical stroke (upper motor neuron; above the facial nucleus in the pons), the upper third of the face is spared in the majority of cases, while the lower two thirds are paralyzed. The orbicularis, frontalis, and corrugator muscles are innervated bilaterally at the level of the brainstem, which explains the pattern of facial paralysis in these cases. [28] Initial inspection of the patient demonstrates flattening of the forehead and nasolabial fold on the side affected by the palsy. When the patient is asked to raise his or her eyebrows, the side of the forehead with the palsy will remain flat. When the patient is asked to smile, the face will become distorted and lateralize to the side opposite the palsy. Otologic examinationAn otologic examination includes pneumatic otoscopy and tuning fork examination. An otologic cause should be considered if the history or physical examination demonstrates evidence of acute or chronic otitis media, including a tympanic membrane perforation, otorrhea, cholesteatoma, or granulation tissue, or if a history of ear surgery is noted. Concurrent rash or vesicles along the ear canal, pinna, and mouth should raise the suspicion for Ramsay Hunt syndrome (herpes zoster oticus). The external auditory canal must be inspected for vesicles, injection or erythema, infection, or trauma. The patient may have decreased sensation to pinprick in the posterior auricular area. Tympanic membranes should be normal; the presence of inflammation, vesicles, or other signs of infection raises the possibility of complicated otitis media. The patient who has paralysis of the stapedius muscle will report hyperacusis. This can be tested clinically using the stethoscope loudness test. In this, the patient wears a stethoscope, and an activated tuning fork is placed at its bell. The loud sound will lateralize to the side of the paralyzed stapedius muscle. Ocular examinationWith weakness/paralysis of the orbicularis oculi muscle (facial nerve innervation) and normal function of the levator muscle (oculomotor nerve innervation) and Mueller muscle (sympathetic innervation), the patient frequently is not able to close the eye completely on the affected side. On attempted eye closure, the eye rolls upward and outward on the affected side. (This is known as Bell phenomenon and is considered a normal response to eye closure.) In addition, the tear reflex is absent in many cases of Bell palsy. For these reasons, the patient may have decreased tearing and susceptibility to corneal abrasion and dryness of the eye. The patient may appear to have loss of corneal reflex on the affected side; however, the contralateral eye blinks when testing the corneal reflex on the affected side. Oral examinationA careful oral examination must be performed. Taste and salivation are affected in many patients with Bell palsy. Taste may be assessed by holding the tongue with gauze and testing each side of the tongue independently with salt, sugar, and vinegar. The mouth must be washed after testing with different substances. The affected side has decreased taste compared with the normal side. Neurologic examinationCareful neurologic examination is necessary in patients with facial paralysis. This includes complete examination of all of the cranial nerves, sensory and motor testing, and cerebellar testing. A neurologic abnormality warrants neurologic referral and further testing, such as MRI of the brain, lumbar puncture, and EMG where appropriate. GradingThe grading system developed by House and Brackmann categorizes Bell palsy on a scale of I to VI. [1, 2, 3] Grade I is normal facial function. Grade II is mild dysfunction. Characteristics include the following:
Grade III is moderate dysfunction. The following characteristics are found:
Grade IV is moderately severe dysfunction. Signs include the following:
Grade V is severe dysfunction. Characteristics include the following:
Grade VI is total paralysis. The following are noted:
In this system, grades I and II are considered good outcomes, grades III and IV represent moderate dysfunction, and grades V and VI describe poor results. Grade VI is defined as complete facial paralysis; all of the other grades are defined as incomplete. An incomplete facial paralysis denotes an anatomically and, to some degree, functionally intact nerve. The degree of facial nerve function should be noted in the chart at the patient’s initial visit. ComplicationsComplications of Bell palsy may include the following:
Author Danette C Taylor, DO, MS, FACN Medical Director, Movement Disorders, Mercy Health St Mary's; Clinical Assistant Professor, Department of Neurology and Ophthalmology, Michigan State University College of Osteopathic Medicine Danette C Taylor, DO, MS, FACN is a member of the following medical societies: American Academy of Neurology, American College of Osteopathic Neurologists and Psychiatrists, American Medical Association, American Osteopathic Association, International Parkinson and Movement Disorder Society Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Acorda<br/>Received research grant from: Neurocrine. Chief Editor Selim R Benbadis, MD Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, Tampa General Hospital, University of South Florida Morsani College of Medicine Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, American Medical Association Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Aquestive, Bioserenity, Ceribell, Eisai, Jazz, LivaNova, Neurelis, Neuropace, Nexus, SK life science, Stratus, Sunovion, UCB<br/>Serve(d) as a speaker or a member of a speakers bureau for: Aquestive, Bioserenity, Ceribell, Eisai, Jazz, LivaNova, Neurelis, Neuropace, Nexus, SK life science, Stratus, Sunovion, UCB<br/>Received research grant from: Cerevel, LivaNova, Greenwich (Jazz), SK biopharmaceuticals, Takeda, Xenon. Additional Contributors Acknowledgements Edward Bessman, MD Chairman, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University School of Medicine Edward Bessman, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine Disclosure: Nothing to disclose. Dominique Dorion, MD, MSc, FRCSC, FACS Vice Dean and Associate Dean of Resources, Professor of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Sherbrooke Faculty of Medicine, Canada Disclosure: Nothing to disclose. Thomas R Hedges III, MD Director of Neuro-Ophthalmology, New England Eye Center; Professor, Departments of Neurology and Ophthalmology, Tufts University School of Medicine Thomas R Hedges III, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Medical Association, and North American Neuro-Ophthalmology Society Disclosure: Nothing to disclose. J Stephen Huff, MD Associate Professor, Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia Health Sciences Center J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine Disclosure: Nothing to disclose. Suzan Khoromi, MD Fellow, Pain and Neurosensory Mechanisms Branch, National Institute of Dental and Cranial Research, National Institutes of Health Suzan Khoromi, MD is a member of the following medical societies: American Academy of Neurology, American Pain Society, and International Association for the Study of Pain Disclosure: Nothing to disclose. Milind J Kothari, DO Professor and Vice-Chair, Department of Neurology, Pennsylvania State University College of Medicine; Consulting Staff, Department of Neurology, Penn State Milton S Hershey Medical Center Milind J Kothari, DO is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, and American Neurological Association Disclosure: Nothing to disclose. Andrew W Lawton, MD Medical Director of Neuro-Ophthalmology Service, Section of Ophthalmology, Baptist Eye Center, Baptist Health Medical Center Andrew W Lawton, MD is a member of the following medical societies: American Academy of Ophthalmology, Arkansas Medical Society, and Southern Medical Association Disclosure: Nothing to disclose. Bruce Lo, MD Medical Director, Sentara Norfolk General Hospital; Assistant Professor, Assistant Program Director, Core Academic Faculty, Department of Emergency Medicine, Eastern Virginia Medical School Bruce Lo, MD is a member of the following medical societies: American College of Emergency Physicians, Emergency Medicine Residents Association, Medical Society of Virginia, Norfolk Academy of Medicine, and Society for Academic Emergency Medicine Disclosure: Nothing to disclose. Arlen D Meyers, MD, MBA Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation Unrestricted gift Unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo Consulting; Medvoy Ownership interest Management position; Cerescan Imaging Honoraria Consulting; GYRUS ACMI Honoraria Consulting Kim Monnell, DO Neurology Consulting Staff, Department of Medicine, Bay Pines VA Medical Center Kim Monnell, DO, is a member of the following medical societies: American Academy of Neurology and American Osteopathic Association Disclosure: Nothing to disclose. Hampton Roy Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology Disclosure: Nothing to disclose. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Medscape Reference Salary Employment Florian P Thomas, MD, MA, PhD, Drmed Director, Spinal Cord Injury Unit, St Louis Veterans Affairs Medical Center; Director, National MS Society Multiple Sclerosis Center; Director, Neuropathy Association Center of Excellence, Professor, Department of Neurology and Psychiatry, Associate Professor, Institute for Molecular Virology, and Department of Molecular Microbiology and Immunology, St Louis University School of Medicine Florian P Thomas, MD, MA, PhD, Drmed is a member of the following medical societies: American Academy of Neurology, American Neurological Association, American Paraplegia Society, Consortium of Multiple Sclerosis Centers, and National Multiple Sclerosis Society Disclosure: Nothing to disclose. B Viswanatha, MBBS, MS, DLO Professor of Otolaryngology (ENT), Chief of ENT III Unit, Sri Venkateshwara ENT Institute, Victoria Hospital, Bangalore Medical College and Research Institute; PG and UG Examiner, Manipal University, India and Annamalai University, India B Viswanatha, MBBS, MS, DLO is a member of the following medical societies: Association of Otolaryngologists of India, Indian Medical Association, and Indian Society of Otology Disclosure: Nothing to disclose. Brian R Younge, MD Professor of Ophthalmology, Mayo Clinic School of Medicine Brian R Younge, MD is a member of the following medical societies: American Medical Association, American Ophthalmological Society, and North American Neuro-Ophthalmology Society Disclosure: Nothing to disclose. Craig H Zalvan, MD Director of Laryngology, Assistant Professor of Otolaryngology, Head and Neck Surgery, Department of Otorhinolaryngology-Head and Neck Surgery, ENT Faculty Practice Craig H Zalvan, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Bronchoesophagological Association, American College of Surgeons, American Laryngological Association, American Laryngological Rhinological and Otological Society, American Medical Association, Medical Society of the State of New York, New York County Medical Society, Triological Society, and Voice Foundation Disclosure: Nothing to disclose. What medication teaching should be provided to a patient experiencing symptoms of Bell's palsy?Commonly used medications to treat Bell's palsy include: Corticosteroids, such as prednisone. These are powerful anti-inflammatory agents. If they can reduce the swelling of the facial nerve, the nerve will fit more comfortably within the bony corridor that surrounds it.
Which assessment finding is associated with initial manifestations of tetanus?Common first signs of tetanus are headache and muscular stiffness in the jaw (ie, lockjaw), followed by neck stiffness, difficulty swallowing, rigidity of abdominal muscles, spasms, and sweating. Patients often are afebrile.
What is the main focus of nursing care for the patient with trigeminal neuralgia?Treatment is aimed at relieving the pain and improving the client's quality of life. The medications of choice to treat trigeminal neuralgia include antiseizure medications like carbamazepine; while alternative options include phenytoin, gabapentin, and baclofen.
Which medication may be prescribed for a patient with chronic pain caused by Bell's palsy?CORTICOSTEROIDS. Oral corticosteroids have traditionally been prescribed to reduce facial nerve inflammation in patients with Bell's palsy. Prednisone is typically prescribed in a 10-day tapering course starting at 60 mg per day.
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Which clinical manifestations would the nurse assess in a patient with Bells palsy?
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