Bells Palsy: what to expect

Let us talk a little about Bells palsy a relatively common neurological condition affecting the function of the seventh cranial nerve (that is the facial nerve).  The muscles of the face are suplied by the facial nerve. It is this nerve which helps you to smile, frown, wrinkle up your forehead, purse your lips and all other facial expressions. The facial nerve is also the nerve which supplies taste sensation to the anterior part of the tongue. It suppiles a muscle called stapedius in the middle ear which helps in damping loud sounds and also supplies the lacrimal gland (helps in tear function).

In Bells palsy patients develop weakness of all the muscles of one half of the face (they cannot close their eye on that side, have a crooked smile as the face gets pulled to the normal healthy side when they attempt to smile, cannot puff their cheeks or purse their lips to whistle). Depending upon the site of involvement of facial nerve, they may also be unable to tear (complaint of dry eye), unable to taste food or complain of excessive loud sounds in the ear on the side of the facial nerve palsy.

In Bells palsy there is inflammation of the facial nerve somewhere along its course from the brainstem to the muscles of the face. In Bells palsy, this inflammation is idiopathic (no definite cause for inflammation is found) though inflammation by the herpes group of viruses has been implicated in its etiology. Some patients have developed Bells palsy after been exposed to cold air (this has never been proved though). Bells palsy is not life threatening but can be quite socially disabling especially if severe (you can imagine how socially disruptive it might be to have one half of your face paralysed and be unable to smile or emote with your face).

Diagnosis and management of Bells palsy: the diagnosis of Bells palsy is clinical (can be made by a clinical examination by a neurologist). In the typical case no further investigations are warranted, though in some cases if the history is atypical (slow onset with addition neurological findings) your doctor may order an MRI study of the brain. 

Most of the patients recover spontaneously from Bells palsy. All that we advise them is to cover the eye at night with an eye patch and wear sunglasses when they go out during the day (this is to protect the eye from keratitis as the eye does not shut). If you present acutely to your doctor with Bells palsy, he may recommend a course of steroids and acyclovir (antiviral drug with efficacy against herpes virus). It is thought that this hastens recovery though some studies have shown that the recovery is the same whether or not acyclovir is used or not).

Your doctor shall also recommend facial exercises (just as you undergo physical therapy if you have a stroke, in the same way we want to encourage facial exercises to hasten recovery). Facial exercises are easy to do and I usually recommend my patients to stand in front of the mirror and attempt to smile, frown, pout and whistle. I ask them to do this for at least 10 mins two times a day. Massaging the face has not been shown to be beneficial. In case the recovery is slow or incomplete your doctor might order a nerve conduction study of the facial nerve to assess the degree of damage to the nerve.

As I stated earlier most patients have a good recovery. At times when the facial nerve regenerates, it regenerates in an arbitary fashion. Patients develop crocodile tears (they start tearing when attempting to eat) or have synkinesis (all the muscles of the face contract at once when attempting to smile that is the fine control of individual facial muscles is lost). If you have these problems you should contact your doctor and ask for advise.

I hope this short post on Bells palsy shall be helpful to some of you.

Personal Regards,

Nitin Sethi, MD

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18 thoughts on “Bells Palsy: what to expect

  1. Great Article.

    I suffered from Bells Palsy about 15 years back, and I remember how little information about this was available at that time. (Forget the Internet, even in the medical community unless you were a specialist). So its good to see you presenting information in a easy to understand way.

    I was treated with steroids to not much improvement after a month, and with some ayurvedic facial pack subsequently which caused it to go away within a week or so just as the guy who gave that pack had indicated. (Not sure if it was the timing of the pack or an otherwise spontaneous recovery which would have happened without it).

    The curious thing that happened was my first cousin also suffered the same illness when she was roughly the same age as when I had it. And went through a very similar (steroids didnt help + ayurvedic recovery a month after). Makes me question – a.) if there is some genetic predisposition to it, in which case there must be a genetic marker associated with it b.) is it really virus related as antivirals and steroids typically haven’t been very effective (even a lot of other anecdotal evidence on the web).

    cheers,
    shubham

  2. Dear Shubham,
    thank you for your comments and for writing in. You raise some very valid points. There was one study which looked at the rate of recovery of patients with Bells Palsy, one group treated with steroids + antivirals and the other just with steroids.That study found that steroids alone were just as effective as steroids+antivirals.

    In any case most of the patients make a good spontaneous recovery whether or not they are treated with anything. We feel the steroids help to hasten the recovery and that is why we prescribe them if we see the patients early enough in the disease course. If the patient presents late say after 1 week, then steroids are probably ineffective.

    As regarding genetic predisposition to Bells palsy, to my knowledge there is none but I shall look into it. It is more likely you and your cousin may have been exposed to the same enviromental/ viral agent.

    My personal opinion (and I agree with you) is that you likely had a spontaneous recovery and the timing of the application of the ayurvedic pack likely coincided with this.

    In any case whatever works is medicine as long it achieves its goal of healing.

    Personal Regards,
    Nitin Sethi, MD

  3. I’ve been reading so much about this…I’m on day 4 of this, and a teacher and haven’t read anything regarding speech being affected which is my case and basically my job. The only way to speak clearly, is for me to pull on the left side of my face…do you think the doctor could write a note or something, because this is embarassing as hell…havent’ been back to work yet but I gotta go, even considering FMLA….please advise.

  4. Dear Kathy,
    your speech is actually not affected. The reason you sound funny and find it hard to speak is because your facial muscles are not working. Hence you are not able to close your mouth to form the words properly, its like trying to speak when you have marbles or a chunk of ice in your mouth.
    This should improve as your facial muscles start to come back. My advise to you would be to take a couple of days off from work, till you regain the strength in your facial musculature. Stand in front of a mirror and exercise your facial muscles at least 3-4 times a day.
    I am sure your doctor shall be able to write a note to explain your absence from work.
    Personal Regards,
    Nitin Sethi, MD

  5. I’ve been suffering from this disease 5 days now. I already consulted a neurologist and she prescribed me with steroids and vitamin b complex. My question is what is the fastest time a patient would fully recover? Will therapy work provided by the hospital? I really want to recover fast since in 3 months time, college graduation pictures would be taken; I want to be able to smile normally and happily just before my college graduation pic will be taken.

    Another question, Can bell’s palsy be caused by staying too long in front of a computer?
    I need your help.
    Thanks for your reply :D

    • Dear Roxanne,
      thank you for writing in. There is no set time for recovery from Bell’s palsy. If the involvement of the facial muscles is mild, one can expect a quick recovery over a couple of weeks. As I stated in my post, most of the patients with Bell’s palsy make a full recovery. Steroids when started early also aid in a quick recovery of the facial nerve function. I would advise you to do the facial exercises recommended to you (stand in front of a mirror, look upwards to make your forehead wrinkle, smile, snarl, puff out your lips-all these exercise your facial muscles).
      As for your last question, no Bell’s palsy is not caused by staying in front of a computer for too long. Our current understanding is that Bell’s palsy occurs due to herpes group of viruses. Why some people get it and what activates the virus suddenly leading to inflammation of the facial nerve is still not known.
      I am sure you shall be able to smile soon and when you do have the college graduation pictures taken do not forget to say cheese!!!

      Personal Regards,
      Nitin Sethi, MD

  6. Dr. Sethi,

    Not sure if you’re still checking comments on this post, but if so…

    I was interested in an earlier comment re: genetic predisposition to Bell’s Palsy. I was just diagnosed four days ago, exactly one week after my mother was diagnosed with the same condition. We were both sick for awhile, so I guess I caught some kind of virus from her, but I’m now trying to figure out if we had similar reactions because we’re so closely related, or if whatever virus we have is more likely to cause Bell’s Palsy. A friend of mine is now experiencing the same symptoms my mother and I did before the onset of Bell’s Palsy (bad cough, fever, just general flu symptoms), and I’m trying to figure out if he’s at risk of developing Bell’s Palsy, too. I’ve read that it’s not contagious, but I’m concerned because I had the exact same reaction as my mother. Again, though, this may be because of a genetic predisposition or just a fluke, who knows. Your blog was incredibly helpful and I was wondering about your opinion.

    Thanks so much for your help.

    • Dear Antoinette,
      There is no known genetic predisposition to Bell’s palsy, at least not described in the medical literature. What is more likely is that you have both got exposed to the same virus. It is though still a mystery why some get the disease and others do not, even though they are exposed to the same bug.
      I wish you a speedy recovery.

      Personal Regards,
      Nitin Sethi, MD

  7. Dear Sharon,
    thank you for writing in to me. Steroids and anti-viral medications such as acyclovir and valcyclovir are used to treat Bell’s palsy (especially if the facial nerve palsy is identified early). Studies have shown that if steroids are used early on in the disease course, the facial nerve paralysis (palsy) may be arrested and recovery is quicker. If the patient comes to medical attention after 7 days, I usually do not treat with steroids or anti-viral medications. Then I just counsel the patient, teach them facial muscle exercises and allow time for spontaneous recovery to take place.
    It might be coincidental that your Bell’s palsy occured at a time when you were on Valtrex and had just completed a short course of steroids. That said and done there is no data to show that long term Valtrex therapy shall prevent a person from getting Bell’s palsy in the first place (meaning that anti-virals or steroids do not prevent Bell’s Palsy).
    Could it not be Bell’s palsy? Well that all important question, I shall have to defer to your physician since I have neither examined you or taken your history.

    Personal Regards,
    Nitin Sethi, MD

  8. I was diagnosed with Bell’s Palsy over 25 years ago (quick recovery) and again 2 days ago (again dramatic improvement). In both instances I was prescribed steroids. The difference I noticed this time was the dull pain behind my left ear. The pain has gone since I started the steroids this time. I can now furrow my forehead nearly full across, smile almost fully and sip through a straw.

    Is my case unusual?

    Thanks.

    • Dear Time,
      thank you for writing in to me. In the medical literature it says it is unusual for Bell’s palsy to recur, though that has not been my personal experience. I have seen patients who have had recurrent Bell’s palsy and when that happens a few diseases come to mind and need to be ruled out namely sarcoidosis, multiple sclerosis, Lyme disease, a lesion at the base of the brain or at the cerebellopontine angle and myasthenia gravis. Also persistent herpes infection may reactivate periodically.
      It is not unusual for patients to notice a dull pain or a sensation of fullness behind the ear a few days before the facial paralysis becomes apparent.

      Personal Regards,

      Nitin Sethi, MD

  9. I was diagnosed with Bell’s palsy last week and I was just wondering is being dizzy and having facial pain also symptoms. Mine came on slowly, each day has just gotten worse. My dr did order a CT and it was clear. I was not sick before this either. The Dr just now started me on steroids so from what I have read my understanding is that it probably won’t help but I feel as if he was stumped as to why I am having so much facial pain. I can not lay on that side of my face or touch it because of the pain. He also gave me some meds for the dizziness but I haven’t seen where that is a symptom. I am also having some swelling in my face. Just trying to find some answers, I don’t want to be like this for long. Thanks for your time!

    • Dear Tandi,
      thank you for writing in to me. Patients who suffer from Bell’s palsy at times do complain of pan though in my personal experience they usually are bothered by weakness of the face muscles (unable to smile, close their eye shut or water dribbling from the side of their mouth when they attempt to swallow). They may at times complain of a sensation of fullness/ pain in or behind the ear. A good neurological history and examination is usually sufficient to diagnose Bell’s palsy and no neuroimaging is usualy warranted. The new generation MRIs (if carried out for some reason) show enhancement of the facial nerve thus confirming the diagnosis. One though needs to rule out other causes of lower motor neuron facial nerve palsy which may at times mimick the presentation of Bell’s palsy. These include infection in the middle ear canal (usually their is discharge or vesicles are seen in the ear canal), brain stem stroke and lesions involving the cerebellopontine angle (such as tumors, abscesses and so forth).
      My advice is that the pain should abate soon. If it persists or your symptoms worsen you should get in touch with your neurologist/ primary care physician.

      Nitin Sethi, MD

  10. Hi i was diagnosed with bells palsy to my right side over three years ago now i am still unable to smile, pout or raise my eyebrow. This has been a massive issue in my life and has caused me a great amount of stress. I have been researching this since i was diagnosed without finding anything that relates. I have also seen a number of doctors that only tell me it will go away eventually. Please help, what can i do to make this horrible thing go away??

    • Dear Kym,
      thank you for writing in to me and I am sorry to hear about the delayed recovery which you have experienced from Bell’s palsy. In the vast majority of cases patients do make a full recovery from Bell’s palsy but in a few some degree of facial weakness (such as a crooked smile) may be left behind. Some patients are left behind with what we neurologists refer to as synkinesis where in the facial nerve fibers do not regenerate or reinnervate in the correct manner leading to abnormal involuntary movements of the face such as tearing (appearance of tears) while eating (chewing).

      You should see a neurologist. He/she may consider ordering a nerve conduction study/ EMG study of the facial nerve and musculature. A blink reflex test can also be carried out. These tests may yield some useful prognostic information–how bad is the damage to the facial nerve and are there any signs of regeneration of nerve fibers. I wish you my best.

      Personal Regards,

      Nitin K Sethi, MD

      • I’ve been diagnosed with bells palcy and its been around 2 and a half months. Recovery is very slow and at the moment I’m undergoing homyopathic treatment. Kindly advice that what shall I do for fast recovery

      • Dear Varad,
        recovery from Bells Palsy at times is slow but in most instances near full recovery takes place. So these are a few things you can do to speed recovery:
        –EXERCISE YOUR FACIAL MUSCLES: stand in front of the mirror and exercise all your facial muscles-the one that makes you smile, the one that makes you frown, the one which makes you purse your lips and whistle, the one that makes you close your eyes tight shut. You can look up some of these exercises on the Internet and start doing them 3-4 times a day.
        –to my knowledge and in my experience-massaging the face with oil does not help or speed up recovery. Likely it does not hamper recovery in any way also.
        –eat a healthy diet.
        –if you drink or smoke, I would advise you to stop smoking and drinking as that hampers the facial nerve recovery.
        –supplement your diet with 2 tabs of a good multivitamin every day.

        Remain in follow up with your doctor/ neurologist.

        I wish you good luck and hope you make a speedy recovery.

        Nitin K Sethi, MD

  11. I have an employee that wants to take FMLA to take care of her adult daughter who has just been diagnosed. From what I can see, there is no care required as the adult daughter is able to take care of her self. Please advise. Thank you

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