BELL'S PALSY - Full extract 

I had just started Saturday morning surgery when I was called to the phone. It was an old schoolfriend who was very worried about his wife.

"Kim is terribly upset," he said. "It looks like she's had a stroke or something. She can't move the right side of her face." I asked them to come straight down. When Kim came into the surgery she was holding a large handkerchief to her face and looked absolutely distraught. "My face has gone all weak," she said. "Look at me, I'm even dribbling out the corner of my mouth,"

Apparently she had a heavy cold over the previous week. She went to bed early and woke with the facial weakness. She also had a dull headache.

When I examined her, she had an obvious paralysis of the facial muscles on the right side and the corner of her mouth drooped a little.

She had also lost the wrinkles on the right side of her forehead, leaving it completely smooth. When I asked her to tightly shut her eyes, the right eye remained almost completely open. She was also unable to puff out her cheek or purse her lips to whistle. A general examination was otherwise normal; her limb movements and reflexes were normal and there was no sign of anything like a stroke. There was little doubt that Kim had Bell's palsy. 

I explained to Kim and her husband as much as I could about the condition and started her on a course of cortisone tablets, initially a high dose but then scaling down. I also gave her advice about using a protective eye patch, as well as some general advice about chewing her food.

I saw Kim several times in the following weeks and we were all delighted to see a steady improvement. After a few months she appeared to have made a full recovery.

The facial nerve has a very important function. It supplies all the muscles of facial expression and is responsible for those movements that we take for granted... smiling, frowning, lifting the eyebrows, closing the eyes and moving the lips and cheeks.

Facial paralysis can occur when a stroke affects the part of the brain where these nerve fibres originate. A very similar picture can occur if the nerve becomes compressed in its narrow canal behind the ear, just as it leaves the skull to supply the various facial muscles. This condition is called Bell's palsy, after the man who first described it in the early 1800s.

The exact cause is not known, but it is probably due to temporary swelling and pressure on the nerve in association with a viral infection of some sort. Some people swear they got Bell's palsy after sitting in a cold draught. We are really no closer to understanding the condition than we were 20 years ago.

The fairly abrupt onset in an otherwise health person is a feature of Bell's palsy. Sometimes the person wakes with the condition and it gets obviously worse over the new few hours. There might also be an associated headache or pain behind the ear on the affected side.

Paralysis of the facial muscles on one side is the main feature of Bell's palsy. A number of subtle differences can help the doctor to decide at what level the facial paralysis has occurred.

In most cases, the diagnosis is quite obvious and no further investigation is required.

If there is any doubt, the doctor may arrange tests like a CT brain scan to rule out the possibility of a stroke, or something like a tumor pressing on the nerve. In some cases, assessment by a neurologist might be advised.

The treatment of Bell's palsy has altered little in recent years. Usually a course of cortisone tablets is recommended to reduce the swelling around the facial nerve.

Analgesics like paracetamol might also be required. Because the affected eye does not close properly, care should be taken that it does not become too dry or uncomfortable, and there is no trauma to the eye. Padding the eye might be necessary initially. Lubricating eye drops might also be of use. Advice is also given about chewing food, as people with Bell's palsy often find that food can get caught between the cheek and teeth.

Various treatments like physiotherapy have been tried but they seem to have little influence on the overall outcome.

In the past, an operation was sometimes performed to relieve the pressure on the nerve. It was of questionable benefit and is rarely, if ever, performed these days.

Some people with Bell's palsy are left with residual weakness of the facial muscles. Fortunately, most people with the condition go on to make a good recovery.

Health Tip:
* There are several causes of facial paralysis, all of which require urgent medical assessment. If facial weakness occurs, contact your doctor immediately.

Dr. Andrew Pattison: Common Consultations
North East Valley Division General Practice, Melbourne, Australia.   Disclaimer
  - Last modified: August 18, 2001