The Diagnosis

Bell’s palsy is a diagnosis of exclusion. During the first visit to a doctor, questions will be asked, and tests may be ordered. These procedures will help the doctor determine the cause of the facial weakness or rule out conditions which are known to be linked to facial paralysis. When no underlying cause is found, Bells palsy is the diagnosis. For example, blisters in the ear or mouth, dizziness or reduced hearing on the affected side may suggest a diagnosis of Ramsey Hunt syndrome.

Slowly progressing paralysis, weakness in areas other than the face, an enlarged parotid gland or paralysis that spares the eye and brow are also among the symptoms may indicate the presence of an underlying condition requiring additional medical attention.

After taking a history and carefully observing the symptoms, tests that may be ordered include various blood tests, MRI, or CAT scan. These tests shouldn’t be a cause for concern. They will either add conviction to a diagnosis of Bell’s Palsy or provide the physician with the information needed to proceed in another direction.

Facial paralysis is a result of nerve damage, and many people look no further for help than to a neurologist. Patients may be unaware that the condition also falls into the realm of Otolaryngology, and that (ENTs) are generally quite knowledgeable in diagnostics and treatment.

IN GENERAL …

The first priority in treating Bell’s palsy or any type of facial paralysis is to eliminate the source of damage to the nerve as quickly as possible. Minor compression for a short time period can result in mild and temporary damage. As time goes on with constant or increasing compression, damage to the nerve can also increase. If you decide to use medications that may help relieve the compression (Prednisone and antivirals), they should be started as quickly as possible. The “window of opportunity” for starting these medications is thought to be 7 days from the onset of Bell’s palsy. Prednisone may be prescribed later if it appears the inflammation has not subsided.

Rest is important. The body has had an injury and will heal most efficiently with enough rest to maintain strength and immunity at peak levels. It’s normal to feel more tired than is usual during recovery. If you choose to work or exercise immediately after onset, be smart about it – when your body tells you it needs a break, indulge it if you have that option.

Food particles can lodge between the gum and cheek, so take extra steps to maintain oral hygiene.

Wear eyeglasses with tinted lenses, or sunglasses (see eye care for additional important information).

Take extra care to keep your eye moist while working on a computer. Even under normal circumstances, people tend to blink less frequently while at a computer. For a dry, non-blinking eye, this can be more of a problem. Keep eye drops handy, and remember to manually blink your eye with the back of the index finger.

If sounds appear painfully loud, don’t hesitate to ask people to speak softly. Exaggerated perception of volume isn’t a symptom that people are likely to be aware of, so you may need to explain that it’s a symptom associated with Bells Palsy. An earplug can help, although if you have a history of inner or middle ear problems or have had surgery in the ear, check with your doctor before using an earplug.

Immediate exercising is not recommended. Unlike skeletal muscles, facial muscles do not immediately start to atrophy. Until the nerve starts to send a signal to the muscles, the muscles simply cannot move. Forcing movement before seeing signs that the nerve is starting to transmit signals again may create long-term problems. Even while the muscles appear flaccid, some nerve threads may be functional. When you try to force movement under these circumstances, you can inadvertently signal the wrong muscles to jump in and help. As time goes on, these inappropriate movement patterns can become automatic. They can result in asymmetrical and synkinetic types of motion. Instead of pushing it in the early days, try to be patient, and remind yourself that in time movement will return. Massage or tapping can provide gentle stimulation without risk.

For pain or discomfort, moist heat can help. There are gel packs and thera-bead packs that can be heated in a microwave for fast, easy and portable help with the soreness. They can usually be found in drugstores and pharmacies, in the section with old-fashioned heating pads. In a pinch, ordinary rice in a sock can be heated in a microwave. For a treat, try an herbal heating pack. Doctors are not all aware that significant pain can be part of the ordeal. If you need medication, ask for it. If the doctor doubts the pain is real, refer him to the recently published “The Facial Nerve, 2nd Edition” for documentation. Severe, or long-lasting pain is more consistently associated with Ramsey Hunt Syndrome. There are several medications that provide relief including Neurontin. This is a relatively new drug for neuropathic and post-herpetic pain. It’s effective for the pain caused by shingles and Ramsay Hunt syndrome and has relatively minimal adverse effects. Common side effects include drowsiness, dizziness, and nausea. Interactions with other drugs are nearly non-existent.

In a study released by the Quality Standards Subcommittee of the American Academy of Neurology (May 2001), Drs. Patrick Grogan and Gary Gronseth pooled the data of existing studies published from 1996 through 2000 regarding the effectiveness of steroids, anti-virals, and decompression surgery as treatment for Bell’s palsy. Their conclusions are:

1. Regarding the use of steroids:
Steroids are “safe and probably effective in improving facial functional outcomes in patients with Bell’s palsy.” Results show significantly better outcomes with steroids. However, they do not find any difference in the time frame for recovery.

2. Regarding the use of antivirals used in combination with steroids:
Based on the limited data available, “acyclovir (combined with prednisone) is safe and possibly effective in improving facial functional outcomes in patients with Bell’s palsy.”

3. Regarding decompression surgery:
“The risk of bias in all studies describing facial outcomes in surgically treated Bell’s palsy patients was too high to support evidence-based conclusions. Additionally, serious complications, including permanent hearing loss, were reported from surgical facial nerve decompression.”

The number of well controlled, unbiased studies available was limited. It is clear that further research is necessary to fully assess the potential benefit of these treatments.