Case Study of the Week: Bell's Palsy

Did you know celeb's such as Katie Holmes, George Clooney and Bachelorette alum Emily Maynard have suffered from Bell's Palsy?  Just one of many interesting things I uncovered while researching for this post.  Let's take a closer look at the diagnosis and treatment of this intriguing disorder.

Bell's Palsy, temporary paralysis of the muscles innervated by the seventh cranial nerve, results from inflammation and swelling of the facial nerve and causes unilateral facial paralysis.  The cause of this swelling and inflammation is largely unknown.  Researchers suspect the facial nerve may become inflamed as a result of recent viral infection, most commonly herpes simplex virus.  Nurse practitioners must be able to distinguish Bell's Palsy from more serious conditions, such as stroke, and be aware of current treatment guidelines to prevent complications.

Case Presentation

A 38 year-old female presents to the emergency department stating that over the past 36 hours, she has developed right sided facial weakness and drooping, an associated right sided ear and jaw ache and inability to close her right eye.  She is unable to move both the upper and lower side of her face.  The patient's vital signs are within normal limits.  She has no significant medical history but does report having an upper respiratory infection about 10 days ago.

On exam, you note weakness on the right side of the patient's face including the forehead (in cases of stroke, the forehead is often spared while the lower two thirds of the face are affected).  The patient is unable to close her right eye completely.  When asking the patient to close her eye, the eye rolls upward and inward on the affected side (Bell phenomenon).  When asking the patient to raise and lower her eyebrows, you note the right eyebrow remains flat.  Upon smiling, the right side of the moth does not rise.  You also note flattening of the nasolabial fold on the affected side.  You continue your neurological exam noting function of all other cranial nerves, aside from the facial nerve, are intact.  Cerebellar exam is also normal.  

Management and Outcome

Bell's Palsy is a diagnosis of exclusion.  It is crucial that nurse practitioners rule out more serious causes of facial paralysis including stroke in diagnosing and treating cranial nerve deficits.  A thorough neurological exam is imperative.  If neurologic abnormalities inconsistent with Bell's Palsy are noted, further testing including MRI of the brain are warranted.  Other diagnoses that must be considered include seventh nerve neoplasm (onset of paralysis is typically slow and progressive), basilar meningitis, Lyme disease and Ramsay Hunt syndrome.  Most often, Bell's Palsy can be diagnosed with history and physical exam.  If unexpected clinical findings are present or if facial paralysis does not resolve as expected, further workup is necessary.

Spontaneous recovery from Bell's Palsy is common and treatment is controversial.  Treatment should be considered in patients presenting within 4 days of onset of paralysis.  Steroids prednisone and antivirals such as acyclovir are the recommended treatment.  Physical therapy including facial exercises have also been shown to result in faster, more complete recovery.  Due to incomplete eye closure in patients suffering from Bell's Palsy, eye protection should be initiated.  Artificial tears for daytime and lubricating ointment at nighttime are used to lubricate the eye protecting the cornea.  An eye patch may also be applied for further eye protection.

80 to 90% of Bell's Palsy cases resolve within a few weeks with no treatment or conservative management.  In severe cases with a poor prognosis, surgical facial nerve decompression can be considered.  Results of this surgery vary and surgical treatment for Bell's Palsy is controversial.  

Discussion

As a nurse practitioner, is it important that you recognize Bell's Palsy and are familiar with it's symptoms and presentation.  You must be able to distinguish Bell's Palsy from other, more serious conditions causing facial nerve paralysis.  Once you have appropriately diagnosed this condition, reassure your patients that Bell's Palsy typically resolves on it's own with minimal lasting impact. 

Comments

Hi Jessica,

We certainly don't know everything!  There isn't one unified database, but there are multiple online and in print resources.  Often, an employer purchases one of these electronic databases as a resource for their providers.  Also, when a patient falls outside an NP's or MD's level or realm of expertise, they refer to another provider with more specialized training.

Erin Tolbert

Your case studies always make me wonder...do doctors, np's, ect. have to know the symptoms for everything or is there some kind of database that helps you guys? Thanks.

Jessica