In-Service Exam
Facial - Palsy - 2002





A 30-year-old man has the sudden onset of weakness of the right eyebrow and cheek and the right side of the mouth. There is no history of trauma or disease; physical examination is otherwise unremarkable. Which of the following is the most appropriate initial step in management?

(A) Observation
(B) EMG
(C) MRI
(D) Facial nerve decompression
(E) Right eyelid tarsorrhaphy

The correct response is Option A.

This patient most likely has Bell's palsy, an idiopathic form of facial paralysis that is the most common diagnosis in persons with facial paralysis (approximately 80%). Diagnosing this condition involves excluding other causes, such as trauma, stroke, and tumor, and thus should be preceded by a thorough evaluation of the patient. Bell's palsy is often associated with diabetes mellitus and pregnancy.

Eighty-five percent of patients who have Bell's palsy will begin to have spontaneous recovery of neurologic function within three weeks. In 15% of affected patients, however, it may take three to six months before some recovery of function is experienced. But because Bell's palsy is rarely permanent, at least some recovery is expected.

Observation for three weeks is indicated prior to performing extensive diagnostic studies. Many of the tests used in the diagnosis of Bell's palsy are expensive and give limited information. Positive findings on electromyography will not be seen until 14 to 21 days after the onset of paralysis. CT scan or MRI may be appropriate after a three-week observation period, if the condition persists. Surgical decompression is not frequently recommended because it increases the risk for injury to the inner ear as well as to the nerve itself; moreover, it has not been clearly shown to be helpful in all cases. Ocular symptoms can generally be managed with artificial tears, use of ointments, and taping until function returns, so eyelid tarsorrhaphy is not necessary.

Although electroneurography (ENOG) will show nerve conduction defects immediately and objectively and is the most accurate and reproducible test currently available to determine the return of facial nerve function, it is generally considered to be prohibitively expensive and time-consuming.

References
1. Aminoff M. Nervous system. In: Tierney LM Jr, McPhee SJ, Papadakis MA, eds. Medical Diagnosis and Treatment. 38th ed. Stamford, Conn: Appleton & Lange; 1999:932.
2. Wells MD, Manktelow RT. Surgical management of facial palsy. Clin Plast Surg. 1990;17:645.