1. DIAGNOSTICS BELL’S PALSY

2. CLINICAL: – Typical presentation – No risk factors or presenting symptoms for other causes of facial paralysis – Absence of neurocutaneous lesions of herpes zoster in the external ear canal – Normal neurologic examination with the exception of the facial nerve

3. Complete blood count Erythrocyte sedimentation rate Thyroid function studies Lyme titer Serum glucose level Rapid plasma reagin (RPR) or Venereal Disease Research Laboratory (VDRL) test Human immunodeficiency virus (HIV) antibodies Cerebral spinal fluid analysis Immunoglobulin M (IgM), immunoglobulin G (IgG), and immunoglobulin A (IgA) titers for CMV; rubella; HSV; hepatitis A virus; hepatitis B virus; hepatitis C virus; VZV; M pneumoniae; and Borrelia burgdorferi

4. MAGNETIC RESONANCE IMAGING Swelling and uniform enhancement of the geniculate ganglion and facial nerve Entrapment of the swollen nerve in the temporal bone Secondary etiology of facial palsy

5. CHEST X-RAY – Possible evidence of Sarcoidosis ELECTROMYOGRAPHY – Prognostic value LUMBAR PUNCTURE – Performed to rule-out other etiologies – Low-grade lymphocytic pleomorphic pleocytosis with normal glucose and protein may be present

6. TREATMENT BELL’S PALSY

7. SYMPTOMATIC Use of paper tape to depress the upper eyelid during sleep and prevent corneal drying and abrasions Lubricating drops for eyes as needed Massage of the weakened muscles

8. GLUCOCORTICOIDS Prednisone – 60-80 mg daily during the first 5 days and then tapered over the next 5 days – Shorten recovery period – Modestly improve functional outcome when initiated in the 1 st 48-72 hours of symptoms

9. SURGERY Facial nerve decompression for proximal, complete deficits No clear evidence in clinical trials for its benefit over standard care

10. MONITORING AND PATIENT EDUCATION Periodic outpatient follow-up – Monitor for resolution of symptoms – Monitor for complications Possible corneal abrasions or ulcerations Eye care – Protect the eye from foreign objects and sunlight. – Keep the eye well lubricated. – Educate the patient to report new ocular findings such as pain, discharge, or visual changes.

11. COMPLICATIONS BELL’S PALSY

12. CORNEAL DRYING AND INJURY – Abrasion – Ulceration INCOMPLETE RECOVERY WITH PARTIAL OR PERMANENT NERVE IMPAIRMENT – Incomplete motor regeneration – Incomplete sensory regeneration

13. PROGNOSIS Group 1 - Complete recovery of facial motor function without sequelae Group 2 - Incomplete recovery of facial motor function, but no cosmetic defects are apparent to the untrained eye Group 3 - Permanent neurologic sequelae that are cosmetically and clinically apparent