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Evaluation of Bell's palsy: Common alternative causes of facial weakness

Evaluation of Bell's palsy: Common alternative causes of facial weakness
  Distinguishing clinical features Additional diagnostic testing*
Stroke
  • Central pattern to facial weakness (spares eye/forehead)
  • Other cranial neuropathies (eg, hearing loss, diplopia, dysarthria)
  • Lateralizing arm/leg weakness and/or numbness
  • Abrupt (sudden) onset to symptoms
 MRI brain without contrast
Lyme disease
  • More likely than Bell's palsy to be bilateral
  • May have systemic symptoms (eg, fatigue, headache, meningismus, lymphadenopathyΔ) either concurrent with facial weakness or in recent past
 Lyme serology
Ramsay Hunt syndrome
  • Vesicles in ear canal
  • Ear pain
 Test lesions for herpes zoster
Guillain-Barré syndrome
  • Reduced/absent stretch reflexes
  • Ataxia
  • Other cranial neuropathies (eg, diplopia)
 Lumbar puncture for CSF analysis NCS and EMG
Tumor (intracranial or parotid)
  • Insidious onset
  • Symptom progression beyond 3 weeks
  • No/minimal improvement within 4 months
 MRI brain and facial nerve with gadolinium
Meningeal disease (eg, infection, neoplasm, inflammatory conditions)
  • Fever, headache, stiff neck
  • Other cranial neuropathies (eg, diplopia, dysarthria)

MRI brain with gadolinium

Lumbar puncture for CSF analysis

CSF: cerebrospinal fluid; EMG: electromyography; MRI: magnetic resonance imaging; NCS: nerve conduction study.

* Specific diagnostic testing may vary by specific risk factors and clinical features. Refer to UpToDate topics for additional details.

¶ Small brainstem strokes that involve the fascicular component of the facial nerve present with a peripheral pattern of weakness that includes eye/forehead along with the mouth. These patients typically also present with other brainstem signs such as dysarthria, vertigo, and/or diplopia.

Δ Lyme disease may present as isolated unilateral or bilateral facial weakness without dermatologic or systemic symptoms. Diagnostic testing to exclude Lyme disease is warranted for patients who present with isolated facial weakness in regions where Lyme disease is endemic.
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