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What Is A Bell’s Palsy? (Facial Droop)

A Bell’s palsy is a weakness of one of the cranial (brain) nerves causing the face to droop. The nerve involved is the seventh cranial nerve. The seventh cranial nerve controls all of the facial muscles. Besides helping the eyes and mouth close, these muscles are important in maintaining facial expressions (Figure 11).

What are the causes of a Bell ’s palsy?
The most common cause of a facial droop is usually a viral infection. The actual virus is rarely isolated. Technically this is very difficult to do. Most facial palsies due to a viral infection usually resolve over a few months. Herpes simplex virus can produce a characteristic Bell’s palsy and can be treated with oral medication (acyclovir, famvir or valtrex).
Some of the more serious causes include a stroke, brain tumor, and parotid gland tumor (a salivary gland just in front of the ear). In addition some patients with lyme disease or facial trauma can present with a seventh nerve palsy.
Sometimes, a facial palsy can result from surgery to remove various tumors. Usually these involve a specific area of the brain or the parotid gland.

How can I recognize a Bell’s Palsy?
People with a Bell’s palsy have a characteristic asymmetry in their face. They look like they have had a stroke. The lip droops, as do all the facial muscles on the involved side. The brow is lower and the eyelid has difficulty closing. Most people will notice difficulty in speaking. This is what usually first alerts most patients that something is wrong. Onset is usually acute; that is happens rather quickly.

What should I do if I recognize these symptoms?
I consider a facial palsy to be a medical emergency. Depending on your age, your doctor needs to make sure that you are not having a stroke. Some strokes can be reversed if caught early enough. Your regular doctor first assesses and treats all Bell’s palsies, not an oculoplastic specialist. A neurologist is frequently involved through consultation.
A work-up usually consists of an extensive history, brain and parotid gland scans, extensive blood work, and complete neurological physical exam.

Is there treatment for a Bell’s Palsy?
Depending on the cause treatment may be available. Clearly if a treatable infection is found like lyme disease, antibiotics can be used.
If a stroke is found, then careful assessment for clot dissolving medications needs to be made. This is usually done in the emergency room by the stroke team. For unknown viral infections, corticosteroids are sometimes used.

What is the role of an oculoplastic specialist in the management of Bell’s Palsy?
An oculoplastic specialist is involved in protecting the eye. Because the muscles around the eye are not functioning properly, the eyelids cannot close completely. This allows the eye to dry out—potentially leading to ulceration, infections and vision loss. This could also be very painful. Initially, protection of the eye is accomplished by aggressive eye lubrication and taping the eye shut at night. Sometimes the eye needs to be temporarily closed with a minor surgical technique. Most patients are not very agreeable to this. A more common method of allowing the eyelid to close better is with the use of a gold weight inserted surgically in the upper eyelid. This allows gravity to help close the eyelid with an attempted blink. Because the eyelid is not surgically closed, acceptance is much greater with this procedure. Maximal vision is maintained. I have been using gold weights for many years with excellent results. These weights are usually temporary. Once the palsy has resolved or the eye is no longer threatened, the weight can be removed with a simple surgical procedure. Once the palsy has resolved or stabilized, patients are still checked regularly.
Patients with chronic facial palsy can have further plastic surgery of the face and eyelids for functional and aesthetic improvement. Frequently, this is performed using an advanced reconstructive team approach.

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