Bell's palsy differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohamadmostafa Jahansouz M.D.[2]

Overview

Bell's palsy must be differentiated from other diseases that cause weakness or total paralysis on one side of the face, difficulty making facial expressions in one side, impaired facial nerve reflexes, salivation and unintended eye closure, such as Ramsay-Hunt Syndrome, Lyme Disease, stroke, Skull fracture, head or neck tumor, and Multiple sclerosis.

Differentiating Bells palsy from other Diseases

• Bell's palsy must be differentiated from other diseases that cause weakness or total paralysis on one side of the face, difficulty making facial expressions in one side, impaired facial nerve reflexes, salivation and unintended eye closure, such as Ramsay-Hunt Syndrome, lyme Disease, stroke, Skull fracture, head or neck tumor, and Multiple sclerosis.

Preferred Table

Diseases	Clinical manifestations						Gold standard of diagnosis	Additional findings
	Symptoms			Physical examination
									Weakness or total paralysis on one side of the face	Difficulty making facial expressions in one side, such as closing eye, smiling and whistling	Salivation	Impaired Facial nerve reflexes	Unintended eye closure with an effort to smile	Incomplete closure and the of the eye when patient attempts to close the eyes Inability to puff the cheek in affected side
Bell's palsy	++	++	++	++	++	++	Exclusion of other causes of facial nerve palsy	Facial droop Pain around the jaw or ear Numbness in the skin of affected side
Ramsay-Hunt Syndrome	++	++	++	++	++	++	Diagnosis is clinical PCR test may be used to confirm the diagnosis	Ramsay Hunt syndrome is caused by the Varicella virus (Herpes zoster) that also causes chickenpox and shingles
Lyme Disease	-/+	-/+	-/+	-/+	-/+	-/+	Enzyme-linked immunosorbent assay (ELISA) Western blot	Erythema chronicum migrans Young patient Heart block Arthritis Vertigo Hearing loss
Stroke	-/+	-/+	-/+	-/+	-/+	-/+	MRI	Sudden unilateral motor and sensory deficit in a patient with a history of atherosclerotic risk factors (diabetes, hypertension, smoking) or atrial fibrillation.
Skull fracture	-/+	-/+	-/+	-/+	-/+	-/+	MRI	History of head injury
Head or neck tumor	-/+	-/+	-/+	-/+	-/+	-/+	MRI	slow onset of the symptoms Headaches Vision problems Difficulty with balance Speech difficulties Personality or behavior changes Seizures
Multiple sclerosis	Rare	-/+	Rare	-/+	-/+	Rare	MRI	Fatigue Mood problems Spasticity Bowel, bladder dysfunction Eye movement problems Sexual dysfunction Visual loss.