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: Mohamadmostafa Jahansouz M.D.[2]

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].

Differentiating X from other Diseases

• [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].

Facial Paralysis

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.

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

• [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						Gold standard for diagnosis	Additional findings
	Symptoms			Physical examination
									Weakness or total paralysis on one side of the face	Difficulty making facial expressions in one side, such as closing eye, smiling and whistling	Salivation	Impaired Facial nerve reflexes	Unintended eye closure with an effort to smile	Incomplete closure and the of the eye when patient attempts to close the eyes Inability to puff the cheek in affected side
Bell's palsy	++	++	++	++	++	++	Exclusion of other causes of facial nerve palsy	Facial droop Pain around the jaw or ear Numbness in the skin of affected side
Stroke	-/+	-/+	-/+	-/+	-/+	-/+	MRI	Sudden unilateral motor and sensory deficit in a patient with a history of atherosclerotic risk factors (diabetes, hypertension, smoking) or atrial fibrillation.
Skull fracture	-/+	-/+	-	-/+	-/+	-/+	MRI	History of head injury
Ramsay-Hunt Syndrome	++	++	++	++	++	++	Diagnosis is clinical PCR test may be used to confirm the diagnosis	Ramsay Hunt syndrome is caused by the Varicella virus (Herpes zoster) that also causes chickenpox and shingles
HIV infection
Head or neck tumor
Multiple sclerosis
Middle ear infection
Injury to facial nerve during labor

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.