Bell's palsy usually begins with the acute onset of unilateral facial weakness. The person may present for medical care suspecting a stroke. Bell's palsy is usually caused by a viral inflammation of the seventh cranial nerve and is diagnosed by the exclusion of other differential diagnoses. This can be accomplished in the primary care office. Once the condition is understood, the nurse practitioner (NP) can help the patient recover, put him at ease, and help save money on costly diagnostic tests and referrals.

History of Present Illness

Nick, a 31-year-old single Caucasian male, presented with a 2-day history of right continuous lateral dull neck and head pain extending through the right postauricular area to the right temporal area. He was quite anxious about what might be happening to him.

Nick was unable to close his right eye and he used tape to hold his right eye closed during the past two nights while trying to sleep. Nick felt he had "no control," and numbness persisted over the right side of his face. Nick took acetaminophen, two tablets every 6 hours, for 2 days with no relief of the pain or numbness. Nick was concerned that he had suffered a stroke and would be permanently disabled.

Review of Systems

Nick denied any recent upper respiratory infections. He denied otalgia, tinnitus, vertigo, or any hearing problems. He had not recently traveled to the northeastern United States. Nick reported no problems with dysphagia, jaw, or facial trauma. He had no reported weight loss. Nick had no past medical history of diabetes mellitus, thyroid conditions, heart disease, hypertension, HIV/AIDS, stroke, seizures, or rashes. He was taking no medications besides the acetaminophen for pain. There were no known allergies to any medications, food, or environmental factors.

Social and Family History

Nick was single and lived in an apartment. He was heterosexual but did not have a girlfriend and he denied any sexual contact for the past 6 months. Nick works full-time and reported no significant stress in his job. There was no reported family history of facial paralysis, stroke, or neurological conditions, such as multiple sclerosis or myasthenia gravis.

Physical Examination

Upon physical examination, vital signs demonstrated a temperature of 98.8^oF, blood pressure of 132/79, pulse of 86, and respirations of 18. Nick was muscular, well conditioned, measured 5'9", and weighed 168 pounds. His speech was fluent and nonphasic, and he appeared at the neurology office in proper dress and exhibiting appropriate behavior. His head was normocephalic in appearance without evidence of trauma. There was facial asymmetry at rest with a smooth right forehead and a flattened right nasolabial fold. His left side of the face revealed voluntary movement.

Distant vision, assessed with the Snellen eye chart, was 20/20 for both eyes. Nick was unable to close the right upper eyelid. There was a widened right palpebral fissure. Pupils were equal, round, and reactive to light and accommodation. The extraocular muscles were intact with no nystagmus. Conjunctivae were clear bilaterally with no exudates. Nick was unable to blink with the right eye and did not respond to the corneal reflex in that right eye. Additionally, the right eye showed decreased tearing. The bilateral funduscopic examination was unremarkable.

The right mastoid was slightly tender. No skin lesions were present in the right postauricular area. The external ear canals were clear, with minimal brown cerumen, and no erythema, discharge, or vesicles bilaterally. The light reflex was present, and tympanic membranes were pearly gray in appearance. Hearing was intact. There was hypersensitivity to noise in the right ear. The Weber test for hearing showed lateralization equally to both ears. The Rinne test determined that air conduction was greater than bone conduction bilaterally.

The nares were patent. Nasal mucosa was pink, moist, and without excessive discharge. There was no jaw tenderness upon bilateral palpation. There was no sagging of the mouth angle. The mouth was void of erythema or lesions. The palate and uvula moved in the midline. Teeth were all present, straight, and in good repair. Gums were pink and intact. The tongue was thick and revealed slow lateral movement. There was no swelling of the parotid glands.

The neck was supple. Nick had a tense right trapezius muscle. The trachea was midline. The thyroid was not palpable. There were no carotid bruits. No lymph nodes were palpable.

The first and second heart sounds were present and crisp. No third or fourth heart sounds were audible. There were no lifts, heaves, or murmurs. The pulmonary system revealed effortless breathing with symmetrical chest expansion. There was resonance to percussion over the lung fields. Breath sounds were clear and no adventitious sounds were heard. Total body skin examination revealed no sign of herpes zoster vesicles, erythema migrans, or cafe au lait spots.

A full neurological exam was conducted. Cranial nerves II - XII were tested. There was a decreased corneal reflex in the right eye. There was an inability to determine sugar and salt on the anterior two-thirds of the tongue. Nick could not smile, whistle, or grimace. There was a decreased sensation to light touch and a pinprick on the right side of the face. There was no voluntary or involuntary movement of the right upper and lower portions of the face. His rating for the House-Brackman facial nerve grading was IV-moderate dysfunction.

Gait was steady. The Romberg test was negative. The deep tendon reflexes were 2+ in all extremities. Muscle strength was 5/5 and sensation was intact in all extremities bilaterally. There were no drifts, tremors, fasciculations, or abnormal movements of the upper and lower extremities. The vertebrae were nontender. There was full range of motion of all joints. Nick not have any contusions.

Differential Diagnosis

The initial list of differential diagnoses for Nick can be classified into the following areas:

* idiopathic - Bell's palsy

* infectious - Ramsay Hunt syndrome, middle ear infection, and Lyme disease

* neurological - stroke and Guillain-Barre syndrome

* neoplasm - parotid tumor

Key classic symptoms of Bell's palsy include:

* unilateral, acute facial weakness of the lower motor neuron type

* postauricular pain

* unilateral lacrimation24

These symptoms develop in 24 to 48 hours, and one-half of all Bell's palsy patients particularly complain about postauricular pain.16 This diagnosis is the most likely, but other possible conditions must be considered.

Ramsay Hunt syndrome is caused by an infectious agent, varicella zoster virus, which is part of the herpes virus family.16 This condition embodies inflammation of the seventh cranial nerve at the geniculate ganglion, producing pain about the eardrum, loss of taste function, complete facial paralysis, and hyperacusis. Herpetic vesicles are sometimes seen in the external auditory canal, as well as in the tympanic membrane."27 Nick had these symptoms, but no vesicles in the ear canal or on the tympanic membrane. Middle ear infection was considered because Nick presented with otalgia and hyperacusis, however the right tympanic membrane revealed no inflammation. There were also no associated symptoms of fever, rhinorrhea, or swolen lymph nodes. As for the possibility of Lyme disease, Nick did not recall any tick bites, nor did he manifest red macular skin lesions. Headache and peripheral facial palsy are common neurological symptoms associated with Lyme disease.20

Figure. Facial Nerve Distribution

Bell's palsy is manifested by entire facial weakness on the affected side.18 A cortical stroke spares the upper third of the affected side of the face while the lower two-thirds of the affected side show paralysis.18 In other words, most strokes do not cause forehead or eyelid muscle weakness.4 The Guillain-Barre syndrome features progressive ascending weakness or paralysis, generally manifested with an onset of symmetrical bilateral weakness.34 Nick lacked this bilateral muscle weakness progression.

Tumors are a consideration when there is a history of facial paralysis evolving over many weeks, positive history of previous cancer, and mass that can be spotted in the ear or parotid glands.13 Neoplasm constitutes about 5% of all facial palsies.10 Nick's onset of facial palsy was abrupt versus a slow onset, as seen in neoplasms. There was a negative finding for the parotid gland examination.

Diagnosis and Manifestations

Bell's palsy affects a single nerve and results in a peripheral mononeuropathy. There is a primary inflammatory process with edema occurring in the confined nerve space. Ischemic pressure is the main reason for the nerve dysfunction.22

The seventh cranial nerve or facial nerve is disrupted and a viral etiology is considered the most likely cause.9 Recent studies implicate the herpes simplex virus type 1 as the cause for Bell's palsy.1,6,8,9,11,14,23 Only two recent studies express skepticism about a herpes connection to Bell's palsy.19,26

Other studies15,32 provide additional insight into links between other etiologies. One study investigated the incidence of cytomegalovirus, rubella virus, and hepatitis A, B, and C viruses in patients with Bell's palsy.32 The results showed an association between hepatitis B and idiopathic facial paralysis. The other study discovered that two individuals being treated with interferon (IFN) alfa 2b and ribavirin for hepatitis C, contracted Bell's palsy.15

Discussion

Both the NP and the neurologist came to a unanimous diagnosis of Bell's palsy based on patient presentation.

Diagnostic evaluations were kept to a minimum, which contributed to cost effectiveness in this case. In fact, Bell's palsy is a diagnosis of exclusion, and approximately 90% of Bell's palsy cases can be diagnosed without the use of costly diagnostic tests.2,24 Prior to being seen at the neurology office, Nick had baseline testing for complete blood count, erythrocyte sedimentation rate, thyroid stimulating hormone, electrolytes, blood urea nitrogen, and glucose, but values were unknown. Additionally, a magnetic resonance imaging was scheduled by the urgent care facility, but not yet done. The cost-conscious neurologist and NP canceled this procedure. Neither provider thought that Nick had a tumor or stroke.

Intervention

Nick's treatment plan consisted of cortisone, antiviral therapy, pain control, eye care, and facial exercises. Nick was also placed on a therapeutic regime of methylprednisolone (Solu-Medrol) and acyclovir (Zovirax) for 10 days.

One evidenced-based review suggests that steroids are probably effective and acyclovir (combined with prednisone) is possibly effective in improving facial function outcomes.12 Since that practice parameter was published, there have been a handful of studies that concur with its recommendation.3,17,30 There have also been some research undertakings that could not substantiate this treatment.21,29 Horowitz28 confirms that evidenced-based data is still controversial with inconsistent findings related to the use of steroids. His observation of more completely resolved Bell's palsy cases today, as compared to the past when steroids were not readily prescribed for this condition, compels him to choose steroids.

Additionally, Nick was given the option to use any over-the-counter nonsteroidal anti-inflammatory drugs for ear pain, when needed. Control of ear pain during the first few weeks after symptom onset is recommended.25 Rest and decreased noise levels dampen hyperacusis.25

Nick was given a choice of artificial tears or Visine twice a day at bedtime and on an as-needed basis for a dry right eye. Additionally, he was instructed to use Lacri-Lube ointment and place an eye patch over his right eye at night. Nick was instructed to report any eye pain or visual problems, since he is at risk for a corneal abrasion and ulceration. His ability to continue to work is advocated with a cautionary message to use safety glasses and sunglasses on a p.r.n. basis.

Preventing eye injuries in cases of individuals with Bell's palsy is imperative, and an ophthalmologist must be consulted if signs of corneal irritation or injury are discovered.25

Facial exercises, consisting of opening and closing the mouth and moving the jaw laterally three times a day and p.r.n. were advised. Facial muscle massage and facial exercises should be done in front of a mirror using the following maneuvers:

* grimacing

* wrinkling the brow

* forcing eye closure

* whistling

* sucking

* pouting

* puffing cheeks and blowing out air22

Neuromuscular facial retraining is 80% effective for those with Bell's palsy.7 Some experts propose integrative manual therapy, which incorporates neural tension techniques to improve blood flow for those afflicted with a facial palsy.33

There are some important educational topics that should be discussed with a person suffering from Bell's palsy. These include:

* disease process, signs and symptoms, and treatment (including side effects of medications

* eye care, comfort measures, necessity of chewing food with unaffected side

* importance of effective oral care and exercise5

* avoiding exposure of face to cold drafts.

Nick was provided with many informational sheets detailing the disease and offering patient education tips. Nick was asked to return to the neurology office in 1 week for follow-up monitoring. Referral results were faxed to the primary care clinician. He was instructed to call the neurology office sooner if there were any problems.

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