The Current Treatment of Bell’s Palsy
Michael J. LaRouere, M.D.
Michigan Ear Institute
Is This a Stroke? How to Tell the Difference
This is the most important question to answer immediately.
Bell’s palsy affects the ENTIRE side of the face, including the forehead. You cannot raise your eyebrow or wrinkle your forehead on the affected side.
A stroke typically SPARES the forehead. If you can still raise your eyebrow and wrinkle your forehead on the weak side, this may not be Bell’s palsy seek emergency evaluation immediately.
Other red flags that suggest stroke or another serious cause:
- Weakness in your arms or legs
- Trouble speaking or understanding speech
- Sudden severe headache
- Vision changes
- Facial paralysis developing slowly over several days or weeks (Bell’s palsy comes on rapidly — within 24–48 hours)
When in doubt, go to the emergency room immediately. Bell’s palsy is frightening but not dangerous. Stroke is a medical emergency.
What Is Bell’s Palsy?
Bell’s palsy is a sudden, one-sided paralysis or weakness of the muscles that control facial expression. It is caused by swelling and inflammation of the facial nerve (cranial nerve VII), which runs through an extremely narrow bony canal in the skull the fallopian canal before branching out to control all the movements on one side of your face.
The most widely accepted cause is reactivation of the herpes simplex virus type 1 (HSV-1) the same virus responsible for cold sores. When the virus reactivates and infects the facial nerve, the nerve swells. Because the canal it travels through is so tight (as narrow as 0.68 mm at its narrowest point), swelling compresses the nerve and disrupts its function.
Bell’s palsy is the most common cause of one-sided facial paralysis, affecting approximately 20–30 people per 100,000 each year. It can occur at any age but is most common between 15 and 60. People with diabetes, high blood pressure, and pregnant women have a higher risk.
What Are The Symptoms of Bell’s Palsy
Bell’s palsy usually comes on suddenly many patients notice it when they wake up or first look in a mirror. The full extent of paralysis is typically reached within 24–48 hours.
Facial symptoms:
- Weakness or complete paralysis on one side of the face
- Drooping of the corner of the mouth
- Inability to close the eyelid on the affected side
- Inability to raise the eyebrow or wrinkle the forehead
- Difficulty smiling, puffing out your cheek, or showing your teeth
- Drooling or difficulty keeping food and liquid in your mouth
Other symptoms:
- Pain behind the ear or in the jaw often begins before the paralysis
- Altered taste on the front portion of the tongue on the affected side
- Sensitivity to loud sounds in the affected ear
- Increased or decreased tearing in the affected eye
- A sensation of facial numbness (without true sensory loss)
Severity ranges from mild weakness to complete paralysis. How severe the paralysis is at its worst is one of the strongest predictors of how well you’ll recover.
Bell’s Palsy vs. Ramsay Hunt Syndrome
Before treatment begins, your doctor must determine which condition you have because the treatment is different and the prognosis is significantly worse for one of them.
Ramsay Hunt syndrome is caused by the herpes zoster virus (the same virus responsible for chickenpox and shingles) reactivating in the facial nerve. It produces facial paralysis similar to Bell’s palsy but is generally more severe, with fewer than 50% of patients achieving full recovery even with treatment.
How to tell them apart: Look carefully for blisters (vesicles) on or around the ear, inside the ear canal, on the roof of the mouth, or on the face or scalp. Ramsay Hunt syndrome is also more likely to involve:
- Significant ear pain
- Hearing loss
- Tinnitus
- Dizziness or vertigo
If vesicles are present, the treatment protocol changes completely higher-dose antivirals are essential and need to begin immediately. This is one of the key reasons why examination by an experienced ENT or neurotologist matters.
Diagnosis
Bell’s palsy is a diagnosis of exclusion other causes of facial paralysis must be ruled out first. Most cases are diagnosed based on clinical presentation alone, but additional testing may be needed.
Physical Examination
Your physician will assess the full extent of facial movement, check for forehead involvement, examine the ear for vesicles, evaluate taste and hearing, and look for any neurological findings that would suggest a central (brain) cause.
Grading — The House-Brackmann Scale
Facial nerve function is graded on a scale from Grade I (normal) to Grade VI (complete paralysis). This grading guides treatment decisions and is used to track recovery over time. Patients with complete paralysis (Grade VI) require additional testing.
Electrodiagnostic Testing (for Complete Paralysis)
For patients with complete facial paralysis, two electrical tests are used within the first 14 days of onset to determine prognosis and guide treatment decisions:
Electroneurography (ENOG) Measures the percentage of facial nerve degeneration by stimulating the nerve at the stylomastoid foramen and measuring the muscle response. Patients with greater than 90% degeneration have a significantly higher risk of incomplete recovery without surgical intervention.
Electromyography (EMG) Detects whether voluntary muscle activity is present, even when no visible facial movement can be seen. If motor unit potentials are recorded during the first two weeks — even with apparent complete paralysis this is a favorable prognostic sign. The absence of any voluntary potentials combined with >90% degeneration on ENOG identifies patients who are most likely to benefit from surgical decompression.
Imaging
MRI is not routinely required but is recommended for atypical presentations, very slow onset, recurrent Bell’s palsy, or no recovery at the expected time. It helps rule out tumors, multiple sclerosis, or other structural causes.