Recognizing Bell’s Palsy in the ED: Cancel the Code Stroke

-Case-
A 41-year-old woman presents to the ED with a sudden onset of left-sided facial droop. She woke up this morning and noticed she couldn’t smile on that side, close her left eye fully, or raise her eyebrow. She denies weakness in her arms or legs, no slurred speech, and has no headache. On exam, she’s alert and oriented with isolated left-sided facial weakness involving the forehead, eyelid, and mouth. Her cranial nerve exam is otherwise normal and there are no other focal neurologic deficits. 

-Evaluation-
Bell’s palsy is an idiopathic, acute, unilateral lower motor neuron (LMN) facial nerve paralysis. It’s the most common cause of facial paralysis and is thought to result from inflammation and edema of the facial nerve, possibly triggered by HSV reactivation.

• Classic Signs:
  • Sudden-onset unilateral facial weakness
  • Inability to close the eye, smile, or raise the eyebrow on affected side
  • No limb weakness or other focal neurologic deficits
    
• Red Flags to Consider Alternative Diagnoses:
  • Gradual onset or progressive symptoms
  • Bilateral facial weakness
  • Presence of systemic symptoms (fever, rash, headache)
  • Additional cranial nerve involvement or focal neurologic findings

Diagnosis:
• Clinical diagnosis based on exam and history
• No imaging or labs needed unless symptoms are atypical or concerning for other causes, particularly stroke

-Management-

1. Steroids:
   • Prednisone 60 mg/day x 5-7 days → Start within 72 hours for best recovery!
2. Antivirals (optional adjunct):
   • Valacyclovir or acyclovir may be added, especially in severe cases or immunocompromised patients; remember – acyclovir is a medication that needs to be taken four times per day – it is not always the best or preferred option for patients!
3. Eye care is essential!
   • Artificial tears and eye patching at night to prevent corneal injury due to incomplete eyelid closure
4. Patient Education:
   • Most patients begin recovering within 2-3 weeks, with full recovery in ~70-90% by 6 months
   • Follow up with primary care or neurology if no improvement in a few weeks

-Fast Facts-

• Forehead involvement = LMN lesion (Bell’s Palsy)
• Steroids are the cornerstone of treatment
• Protect the eye to prevent corneal ulceration
• Most cases resolve spontaneously, but early treatment improves outcomes!
• Keys to discern between Bell’s palsy and stroke:

Bell’s palsy is a high-anxiety presentation for both patients and providers. Sudden-onset, unilateral facial weakness screams stroke at first glance, but forehead involvement can tell a different story. In the ED, distinguishing Bell’s palsy from a central lesion is key; start steroids, protect the eye, and reassure your patient: the face may not be smiling now, but recovery is on the way.

Want to learn more? Read our in-depth study guide and listen to our podcast episode on this topic!

Cheers,

Tamir Zitelny, MD

-References-

1. Baugh RF, Basura GJ, Ishii LE, et al. Clinical practice guideline: Bell’s palsy. Otolaryngol Head Neck Surg. 2013;149(3 Suppl):S1-S27. doi:10.1177/0194599813505967
2. Holland NJ, Weiner GM. Recent developments in Bell’s palsy. BMJ. 2004;329(7465):553-557. doi:10.1136/bmj.329.7465.553
3. Tiemstra JD, Khatkhate N. Bell’s palsy: diagnosis and management. Am Fam Physician. 2007;76(7):997-1002.
4. Peitersen E. Bell’s palsy: the spontaneous course of 2,500 peripheral facial nerve palsies of different etiologies. Acta Otolaryngol Suppl. 2002;(549):4-30. doi:10.1080/000164802760370736
5. Gilden DH. Bell’s palsy. N Engl J Med. 2004;351(13):1323-1331. doi:10.1056/NEJMcp041120