Bell's palsy differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Overview

[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].

OR

[Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].

Facial Paralysis

Facial paralysis is a loss of facial movement due to nerve damage. Your facial muscles may appear to droop or become weak. It can happen on one or both sides of the face. Common causes of facial paralysis include:

• infection or inflammation of the facial nerve
• head trauma
• head or neck tumor
• stroke

Facial paralysis can come on suddenly (in the case of Bell’s palsy, for example) or happen gradually over a period of months (in the case of a head or neck tumor). Depending on the cause, the paralysis might last for a short or extended period of time.

Massive Stroke: Symptoms, Treatments, and Outlook »

Bell’s palsy

According to the National Institute of Neurological Disorders and Stroke, Bell’s palsy is the most common cause of facial paralysis. Every year, around 40,000 Americans experience sudden facial paralysis due to Bell’s palsy. This condition causes inflammation of the facial nerve, which commonly causes the muscles on one side of the face to droop.

No one knows exactly why Bell’s palsy occurs. It may be related to a viral infection of the facial nerve. The good news is that most people with Bell’s palsy recover completely in about six months.

Bell’s Palsy »

Stroke

A more serious cause of facial paralysis is stroke. Facial paralysis occurs during a stroke when nerves that control the muscles in the face are damaged in the brain. Depending on the type of stroke, damage to the brain cells is caused by either lack of oxygen or excess pressure on the brain cells caused by bleeding. Brain cells can be killed within minutes in each case.

Other causes

Other causes of facial paralysis or weakness include:

• skull fracture or injury to the face
• head or neck tumor
• middle ear infection or other ear damage
• Lyme disease, a bacterial disease transmitted to humans by a tick bite
• Ramsay-Hunt Syndrome, a viral reactivation that affects the facial nerve
• autoimmune diseases such as multiple sclerosis, which affects the brain and spinal cord, and Guillain-Barré syndrome, which affects the nervous system

Birth can cause temporary facial paralysis in some babies. However, 90 percent of babies with this type of injury recover completely without treatment. You can also have facial paralysis at birth due to certain congenital syndromes, such as Mobius syndrome and Melkersson-Rosenthal syndrome.

• [Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].
• [Disease name] must be differentiated from [differential dx1], [differential dx2], and [differential dx3].

• As [disease name] manifests in a variety of clinical forms, differentiation must be established in accordance with the particular subtype. [Subtype name 1] must be differentiated from other diseases that cause [clinical feature 1], such as [differential dx1] and [differential dx2]. In contrast, [subtype name 2] must be differentiated from other diseases that cause [clinical feature 2], such as [differential dx3] and [differential dx4].

Preferred Table

Diseases	Clinical manifestations						Para-clinical findings							Gold standard	Additional findings
	Symptoms			Physical examination
							Lab Findings			Imaging			Histopathology
	Symptom 1	Symptom 2	Symptom 3	Physical exam 1	Physical exam 2	Physical exam 3	Lab 1	Lab 2	Lab 3	Imaging 1	Imaging 2	Imaging 3
Bell's palsy
Stroke
Skull fracture
Lyme disease
Ramsay-Hunt Syndrome
HIV infection
Head or neck tumor
Multiple sclerosis
Head or neck tumor
Head or neck tumor
Head or neck tumor

Differential diagnosis of Bell's palsy

Lyme Disease

• Facial nerve palsy is the most common cranial neuropathy associated with Lyme meningitis.
• Screening for antibodies to B. burgdorferi not recommended among patients with seventh nerve palsy with no additional manifestations of Lyme disease.
• Findings suggestive of possible Lyme disease include the development of facial palsy in a young patient, heart block, arthritis, vertigo, and hearing loss.

HIV

• HIV infection rarely causes facial palsy.
• Onset at the time of sero-conversion when a CSF lymphocytosis is usually present.
• In the later stages when cellular immunity wanes, the facial palsy is typically due to another infection such as Zoster, chronic demyelinating polyradiculopathy, or meningeal lymphomatosis.

Melkersson-Rosenthal Syndrome

• Facial paralysis, episodic facial swelling, and a fissured tongue, typically beginning in adolescence, with recurrent episodes of facial palsy.
• Incomplete forms of this syndrome outnumber those with the classic triad.
• The cause is unknown, and treatment unproven.

Other Entities

• Bacterial infection of the middle ear (otitis media)
• Cholesteatoma, or tumors should be suspected if the onset of facial palsy is gradual.
• Sarcoidosis, especially in patients with bilateral facial palsy.
• Sjogren's syndrome is an unusual cause.