Bell’s Palsy

15-26 Bell’s Palsy

Reed Pence: Mandy was a real estate broker in suburban Chicago fifteen years ago, when she was pregnant with her third child. That’s when she had a scare she’ll never forget. It started with a sharp pain behind her right ear. But when that pain went away, Mandy dropped it from her mind until the next day.

Mandy Andujar: I remember having breakfast one morning and noticing that the food tasted different. I didn’t really pay much attention to that, and went on with my day, but I kept noticing that throughout the day with other meals, and then it was the next morning after that that I remember waking up and seeing that my face didn’t look the same. The left side of my face seemed to be drooping, where I had no ability of movement of facial muscles. I tried drinking something that morning, and I remember not being able to put my lips up to the cup on that side of my face. I was very much in shock. I was thinking, “Is this a stroke?” “Is something else happening?” and I was very afraid.

Pence: Mandy went to the emergency room and fortunately, it wasn’t a stroke, but what Mandy did have can mimic some of a stroke’s symptoms and can certainly end up being serious. She was diagnosed with “Bell’s Palsy,” a condition where the facial nerve for one side of the face simply stops working.Dr. Steven Lewis is Professor and Associate Chairman of the Department of Neurological Sciences at the Rush University Medical Center in Chicago.

Steven Lewis: The classic symptom of Bell’s Palsy that really is what catches the patient’s attention is that they are weak on one side of their face, so they see that they are unable to close one eye, or they’re weak in closure of one eye, they’re unable to smile on one side of their face or raise the eyebrow on that side of their face. What’s commonly known by patients and even some physicians is that prior to facial weakness, patients often have pain behind the ear on the side of the weakness. So they may have pain for a day or so behind the ear and then a day or so later, start developing this weakness.

Lisa Ishii: Many patients think that they are experiencing a stroke because they have this sudden onset of changing to the sensation and motion typically in one side of their face.

Pence: That’s Dr. Lisa Ishii, Associate Professor of Otolaryngology-head and Neck Surgery at the Johns Hopkins School of Medicine.

Ishii: They realize that they are having difficulty speaking because one half of their mouth is not moving the same way as the other. They may have trouble closing their eye, and they may feel like their eye is dry. Patients will also state that they feel like the sensation is different, so in other words, they’ll say they feel like their face is numb. Technically it’s not, because Bell’s Palsy is a motor nerve problem. It’s usually quite disconcerting, so patients are typically extremely concerned about it when it has its onset.

Pence: Ishii says Bell’s Palsy is relatively rare, affecting about one person in every 5,000. Doctors know that it results when one of the facial nerves shuts down, and it appears to be more common in people who are diabetic and women who are pregnant. However, Lewis says why the nerve malfunctions is unknown.

Lewis: One current thought, and probably the most popular hypothesis, is that this relates to some kind of viral infection of the nerve, but it’s really not entirely proven.  We do think in general there’s some kind of inflammation, maybe even a little swelling of the nerve somewhere, but whether it’s actually triggered by a virus or something else isn’t entirely clear.

Kerry Schrambeck: I thought I had cold symptom, so like a runny nose and watery eyes, and I had a pain behind my left ear. I thought I was actually having a tooth abscess.

Pence: Kerry Schrambeck of Lake Villa, Illinois, developed Bell’s Palsy last April.

Schrambeck: The pain didn’t go away behind my ear, it was constant.  My left eye was watering really bad, so I thought I had pink eye. I thought “Well that kind of goes with the cold.” But then everyday I noticed my face started looking weird and feeling weird and I wasn’t able to eat. I wasn’t able to smile. I wasn’t able to put food in my mouth because I couldn’t move the left side of my face.  Then my eye wasn’t blinking and I thought, “This isn’t normal.” I was at work and I was slurring my words. I couldn’t drink out of a soda bottle. I was kind of drooling. Then I thought, “This isn’t right.”

Pence: Kerry called her doctor, who seemed pretty calm about it.

Schrambeck: The first thing he said was “Do you have a cold or a virus or an infection?” and I said “I think I have a cold.” And he said, “You have Bell’s Palsy.” He said, “Go to the emergency room to make sure you didn’t have a stroke.” Because of my age being forty-five he said I wasn’t a “spring chicken”.  I went to the ER and the first thing they said was, “Do you have a cold?” and I said, “Yes.” They said, “You have Bell’s Palsy. Before they even admitted me they knew exactly what it was. I had textbook symptoms.

Pence: Kerry also had a textbook recovery. She received oral prednisone, a steroid, to help the process along.

Schrambeck: Maybe [after] three days I started noticing, because I would look in the mirror all the time just to see, because it was kind of funny, if I smiled or laughed. I was just wanting to see the progress, and I could see that part of my smile was coming back. The eating and drinking part probably took the longest. My eyes stopped watering almost the next day after I started with the medicine.

Pence: Steroids help speed the process, but Lewis says most patients would recover completely on their own without it. Usual recovery time is four to eight weeks.

Lewis: About 70% of people will make a complete recovery, and of that remaining 30%, most will make a very good recovery. A few will not recover as well. Our intention as physicians is to increase the chances of a very good recovery in a condition that already has a good chance of a very good recovery. There is pretty good evidence that steroids given early in the course of Bell’s Palsy, [using] studies typically done within three days of the onset, further improve one’s chances of a good recovery.

Ishii: There has been a fair amount of usage and discussion around the use of antiviral therapies, [though] the data is less clear. We’ve recommended against treating with antiviral therapy alone, because there wasn’t good enough data to say whether or not the addition of antiviral therapy to steroid therapy was better than steroid therapy alone. Our recommendation in the guideline was that you could add antiviral therapies, but we didn’t know with evidence that was better than an oral steroid alone.

Pence: However, Ishii says just because Bell’s Palsy often goes away on its own doesn’t mean it’s not serious.

Ishii: What makes it serious is what we are talking about is the function of half of your face. So there are functional deficits that can occur, like those that I mentioned: difficulty chewing, and one that I didn’t mention: difficulty breathing through the nose from having one side of your nose be flaccid, so the side wall is collapsing down on itself and causing blockage on one side of your nose. It can be extremely critical if individuals cannot close their eyelid completely and their eye is exposed; it can get dried out. You can get an ulcer on your cornea, which can lead to blindness.

Pence: Ishii says taking care of that eye problem can require unusual steps.

Ishii: What we do is tell the patients to lubricate their eye with eye droops. Depending on the amount of exposure that they have, what we encourage them to do at night, when they’re sleeping for example, is use what’s called a moisture chamber. They can literally take a piece of saran wrap and tape it around the involved eye. What that does is trap moisture while they’re sleeping to help provide some lubrication since they aren’t doing it themselves.

Pence: Ishii says patients also have to deal with severe social effects when half of their face doesn’t work right.

Ishii: They are unable to express emotion in a normal way. We’ve done research on this to measure how they are perceived, and they are perceived quite negatively, both from an attractiveness standpoint and from the standpoint of “what type of emotion are they trying to convey”, whereby when a patient has this deficit, especially in the extreme stages of it, rather than being interpreted as happy, they’ll be interpreted as angry.  So it has tremendous impact on their social interactions with others.

Pence: That’s similar to what happened to Mandy. She says when she had Bell’s Palsy 15 years ago, little treatment was available, and her symptoms dragged on for nearly a year.

Andujar: There really wasn’t any improvement until months later. I remember the next few weeks just trying to do my best in terms of eating [and] drinking. Of course I was very embarrassed to look at people. I couldn’t smile correctly, so I tried to keep away from social events and hide myself away from the public as much as I could. Being in real estate sales, that was very difficult to do because I’m in front of customers all the time. So it was very challenging for the next few weeks and I didn’t see improvements until months later.

Pence: That’s why Ishii says one key area of recovery involves training patients and their families about Bell’s Palsy, because it’s often misunderstood.

Ishii: Based on what we know about the impact to the patient from a psychosocial standpoint, they need to be educated, and their friends and family need to be educated. They need to understand the differences that can occur in their social interactions and with loved ones, and whatever kind of help they can be given in terms of getting through that.

Pence: However, “getting through it” can become a lifelong process. Even among patients who make a good recovery, it’s common for some effects to never go away. Ishii says the face may remain slightly asymmetrical, particularly on smiling. Or the patient may suffer from what’s called synkinesis.

Ishii: Which is where you get abnormal facial nerve function. What I mean by that is that the facial nerve has multiple branches, which go to different muscles in the face. So an example of synkinetic motion is if someone goes to smile and they fire the nerve to make muscles move that would lead them to smile, their eye will blink involuntary when they do that because at the same time they’re firing the nerve to the muscle that goes around their eye. So that’s another residual effect from this that can occur.

Pence: Mandy still has synkinetic effects fifteen years after first being afflicted with Bell’s Palsy.

Andujar: It’s very difficult to close the eye completely. Even to this day, one symptom that has never gone away is when I eat, my left eye tears as if I am crying. And it’s funny because when I eat people think I am crying. I always get asked, “Are you okay?” but it just tears. Even though my face is mostly recovered it is not 100%.My left side still seems to droop slightly and when I try to even whistle, the left side of my lips doesn’t quite form as well as the right side. So I’m probably at 95% of normal. I’m very happy about that.

Pence: Kerry Schrambeck has some happiness over her Bell’s Palsy, too. She knows she’s been fortunate to have a quick recovery, even though she’s had unpleasant lingering effects, too, such as facial twitching. But Kerry says one good thing has come out of it. One effect that she hopes will stick around.

Schrambeck: My smile isn’t the same anymore. If you didn’t know me you could never tell, but I can tell I don’t have the same smile that I used to. I don’t know, it’s hard to describe. I just didn’t like it before but now it’s kind of cute.

Pence: You can find out more about all of our guests on our website radiohealthjournal.net, where you can also find archives of all our shows. You can also find our shows on iTunes and Stitcher.

I’m Reed Pence.