Bell's palsy differential diagnosis

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

Overview

[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].

OR

[Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].

Facial Paralysis

Facial paralysis can come on suddenly (in the case of Bell’s palsy, for example) or happen gradually over a period of months (in the case of a head or neck tumor). Depending on the cause, the paralysis might last for a short or extended period of time.

Stroke

A more serious cause of facial paralysis is stroke. Facial paralysis occurs during a stroke when nerves that control the muscles in the face are damaged in the brain. Depending on the type of stroke, damage to the brain cells is caused by either lack of oxygen or excess pressure on the brain cells caused by bleeding. Brain cells can be killed within minutes in each case.

Other causes

• [Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].
• [Disease name] must be differentiated from [differential dx1], [differential dx2], and [differential dx3].

• As [disease name] manifests in a variety of clinical forms, differentiation must be established in accordance with the particular subtype. [Subtype name 1] must be differentiated from other diseases that cause [clinical feature 1], such as [differential dx1] and [differential dx2]. In contrast, [subtype name 2] must be differentiated from other diseases that cause [clinical feature 2], such as [differential dx3] and [differential dx4].

Preferred Table

Diseases	Clinical manifestations						Para-clinical findings							Gold standard	Additional findings
	Symptoms			Physical examination
							Lab Findings			Imaging			Histopathology
	Symptom 1	Symptom 2	Symptom 3	Physical exam 1	Physical exam 2	Physical exam 3	Lab 1	Lab 2	Lab 3	Imaging 1	Imaging 2	Imaging 3
Bell's palsy
Stroke
Skull fracture
Lyme disease
Ramsay-Hunt Syndrome
HIV infection
Head or neck tumor
Multiple sclerosis
Middle ear infection
Injury to facial nerve during labor
Diabetes mellitus

Differential diagnosis of Bell's palsy

Lyme Disease

• Facial nerve palsy is the most common cranial neuropathy associated with Lyme meningitis.
• Screening for antibodies to B. burgdorferi not recommended among patients with seventh nerve palsy with no additional manifestations of Lyme disease.
• Findings suggestive of possible Lyme disease include the development of facial palsy in a young patient, heart block, arthritis, vertigo, and hearing loss.

HIV

• HIV infection rarely causes facial palsy.
• Onset at the time of sero-conversion when a CSF lymphocytosis is usually present.
• In the later stages when cellular immunity wanes, the facial palsy is typically due to another infection such as Zoster, chronic demyelinating polyradiculopathy, or meningeal lymphomatosis.

Melkersson-Rosenthal Syndrome

• Facial paralysis, episodic facial swelling, and a fissured tongue, typically beginning in adolescence, with recurrent episodes of facial palsy.
• Incomplete forms of this syndrome outnumber those with the classic triad.
• The cause is unknown, and treatment unproven.

Other Entities

• Bacterial infection of the middle ear (otitis media)
• Cholesteatoma, or tumors should be suspected if the onset of facial palsy is gradual.
• Sarcoidosis, especially in patients with bilateral facial palsy.
• Sjogren's syndrome is an unusual cause.