Management Bell's Palsy
A patient with Bell’s palsy cannot fully close the affected eye. Explain why this finding changes your management and describe the measures you would institute.
Loss of orbicularis oculi function > corneal exposure > drying, keratitis and ulceration. Use artificial tears, lubricating ointment, eyelid taping/closure at night, and escalate if ocular symptoms develop.
Initial assessment of stroke involves CT scan, which is used to determine the type of stroke in order to determine what kind of management is needed. In this CT scan, which is ischaemic/haemorrhagic stroke?
Left is haemorrhagic, right is ischaemic.
Left: hyperdense white section is the haemorrhage.
Right: Lack of blood flow results in hypodense appearance on CT.
How many patients with Bell’s Palsy make a full recovery? How does corticosteroid treatment affect this?
70-80% make a full recovery with no treatment. Closer to 80-90% with timely corticosteroid treatment.
Approximately what proportion of Australian patients admitted with acute stroke die during their hospital admission?
~9% in the 2023 Australian Stroke Clinical Registry cohort
A patient with acute facial paralysis also reports severe ear pain and you identify vesicles within the external auditory canal. Explain how this changes your diagnosis and management.
Suggests Ramsay Hunt syndrome due to VZV rather than idiopathic Bell’s palsy. Antiviral therapy becomes much more important, generally alongside corticosteroids, with assessment for hearing/vestibular involvement.
The acute management of ischaemic stroke includes administering intravenous thrombolysis within ____hours of symptom onset. Mechanical clot retrieval (endovascular thrombectomy) may be necessary up to ______ hours in patients with salvageable tissue.
23-25% of patients with Bell’s Palsy report elevated levels of anxiety and depression. Why might this be?
Identity, commonly tied to face, through emotion, communcation
-Difficulties completing day to day activities the same e.g. eating, speaking
-Social isolation. Struggles in showing emotion in face, eating in public, stigma
Give three major characteristics of the stroke itself that influence a patient's prognosis.
stroke type — ischaemic versus haemorrhagic
stroke severity
size of the affected area
anatomical location
level of consciousness
involvement of critical structures such as the brainstem
A patient presents five days after the onset of otherwise typical Bell’s palsy. Discuss how the timing of presentation affects your treatment decisions.
Corticosteroids are most beneficial when started early, ideally within 72 hours. Benefit is less certain after this window, so management becomes more focused on eye protection, monitoring, and reassessing for atypical causes
Chronic management of stroke involves rehabilitation, secondary prevention and risk factor/lifestyle modification. Give an example of each.
Rehabilitation - physical therapy, speech-language therapy - to recover lost motor, swallowing and cognitive functions
Secondary prevention - antiplatelets, statins, oral anticoagulants reduce risk of thrombus formation in the heart if the patient has atrial fibrillation
Lifestyle modification - dietary changes (low salt) for hypertension and cholesterol. Management of diabetes, which is a risk factor of stroke. Smoking cessation.
Several months after recovering from Bell’s Palsy your patient comes in reporting their eye closing when they smile. Why could this have occurred?
Motor synkinesis: occurs as facial nerve regrows and heals, can lead to differences in the new branching and innervation of the muscles. Leading to involuntary movements of facial muscles when doing other voluntary movements.
A patient recovering from Bell’s palsy is fully independent in daily life but still has facial asymmetry, incomplete eye closure and involuntary eye movement when smiling. Explain why a general disability scale such as the modified Rankin Scale may underestimate the severity of their residual deficit, and what type of assessment would be more informative.
The mRS measures overall functional independence, so a patient can score very well despite having substantial residual facial nerve dysfunction. A facial nerve-specific grading system, such as the House–Brackmann scale or Sunnybrook Facial Grading System, would better assess the degree of facial weakness. Sunnybrook is particularly useful because it separately assesses resting symmetry, voluntary facial movement and synkinesis.