Case of the day – Bell’s (7th Cranial Nerve Palsy)

THANK YOU TO MY PATIENT FOR HER PERMISSION TO USE HER PHOTO FOR MY BLOG

This woman presented with acute onset numbing and paralysis of the right side of her face.  She also had difficulty blinking, and had less tears than usual on the right eye causing her discomfort and when she drank water some would dribble out the side corner of her mouth.  She noticed all this upon waking the previous morning before presenting to the clinic.

She also had a history of having flu-like symptoms (runny nose, watery eyes and slight cough which resolved spontaneously without any treatment (as typical of the viral upper respiratory infections – though patients came in demanding antibiotics).

She had been previously well and had no past significant medical or surgical history.

In particular she did not have a history of:

  • Herpes simplex virus
  • Diabetes mellitus
  • Hypertension
  • Thyroid disorders

Which have been shown to have some association with Bell ’s palsy.

Herpes zoster virus can be a cause and if so, zoster vesicles can be seen on the same sided ear – and is termed Ramsay-Hunt syndrome.

Upon examination – when asked to wrinkle her forehead, only the left side of her forehead wrinkled, while the right remained relatively flat.  When asked to smile, the left side of her mouth curved as in a smile while

Patients, quite understandably are usually very anxious when they present and need appropriate reassurance that it is a benign condition. (After ruling out an upper motor neuron lesion, in which case the forehead muscles will be spare and the patient will be able to wrinkle both sides of the forehead.  About 80% will recover fully within 3-6 months.  Some cases may take longer and a small proportion may persist indefinitely. This fact is both a source of reassurance and anxiety.  My patient today initially express relief and the a little anxiety by saying: “I hope I fall into that 80%”

Treatment of Bell’s Palsy include:

  • Appropriate reassurance
  • Prednisolone 75mg oral in 3 divided doses for 3 days, then tapering this off to zero over 14 days
  • Adhesive patch to protect the eye especially in dusty, windy conditions
  • Artificial tears – eye drops
  • Light massage of facial muscle

Image

Image

 

The patient came in for review about 2 weeks later.  Apart from being nicknamed Cpt Hook at her office, her recovery was uneventful.  She had a pretty much normal smile now and was able to wrinkle both sides of her forehead.

recovered1

recovered2

About Dr. Poyap J Rooney

Dr. Rooney is a medical doctor who has gained both his undergraduate medical degree and more recently his post graduate masters degree in clinical biochemistry at the University of Papua New Guinea.
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