It’s 4pm on Monday and you’re the resus resident at Sinai with all 5 beds full and 2 more waiting in the hallway. Despite channeling your inner Stephanie Hernandez you’re still completely overwhelmed. The triage nurse calls yet another resus patient overhead and this time it’s a stroke alert. You see this patient in triage:

Bell's_palsy_summary

Do you activate the stroke team or send this patient to the intake/fast track area?

Bell’s palsy is a peripheral neuropathy that typically affects cranial nerve 7. Inability to wrinkle the forehead points the diagnosis heavily towards Bell’s; forehead sparing suggests an upper motor neuron lesion more consistent with a central etiology such as stroke. Most cases of bell’s palsy are presumed to be caused by herpes simplex or herpes zoster virus, and it is a clinical diagnosis.

Several recent meta-analyses show a benefit from corticosteroid treatment if initiated within 3 days of onset of symptoms (1). However, antivirals have not shown to have any benefit in outcomes (2). The verdict: give prednisone 60-80mg x7 days +/- antivirals.

What you should tell your patient about recovery:
Prognosis is dependent on the severity of the lesion, and symptoms that improve within 21 days tend to recover completely. Follow up is key to long term management.

Other things to consider:
-In some cases, there is poor eyelid closure and reduced tearing. Artificial tears should be prescribed to prevent complications such as blindness. Patches can be used at night.
-Consider lyme disease and send titers if patient has recently traveled to endemic areas.
-Other causes of cranial nerve palsy include tumors (schwannomas, cholesteatomas, etc), HIV infection, Guillan-Barre, and Sjogren’s syndrome. Work these up in the appropriate clinical context.

1) Meta-analyses: http://fampra.oxfordjournals.org/content/31/6/631/T2.expansion.html

2) Valcyclovir RCT:
http://www.sciencedirect.com/science/article/pii/S1474442208702217