Bell Palsy: The Daily PANCE Blueprint
A 34-year-old woman woke this morning unable to move the left side of her face. Over a few hours it has become complete. She cannot close her left eye or wrinkle the left side of her forehead, her smile pulls to the right, and food pockets in her left cheek. She reports decreased taste on the front of her tongue and that sounds seem uncomfortably loud in the left ear. Strength and sensation in her arms and legs are normal, her speech is clear, and the remaining cranial nerves are intact. There is no rash in or around the ear. Which of the following is the most likely diagnosis?
A. Bell palsy
B. Ischemic stroke of the left middle cerebral artery
C. Ramsay Hunt syndrome
D. Lyme neuroborreliosis
E. Acoustic neuroma
Answer and topic summary
The answer is A. Bell palsy
Acute unilateral facial weakness that INCLUDES the forehead is a peripheral seventh nerve palsy — Bell palsy — and that single exam finding is the whole question. The forehead has bilateral cortical innervation, so a central (upper motor neuron) lesion such as a stroke spares the forehead and the patient can still raise that eyebrow; a lower motor neuron lesion of the nerve itself knocks out the entire half of the face. The extra findings all localize along the facial nerve’s course: loss of taste on the anterior two-thirds of the tongue (chorda tympani) and hyperacusis (stapedius). Bell palsy is idiopathic but strongly linked to reactivated herpes simplex virus, and it is a clinical diagnosis — no imaging needed when the exam is isolated and typical. Treat with oral corticosteroids started within 72 hours (prednisone 60–80 mg daily for a week), consider adding an antiviral for severe or complete palsy, and — the detail most often forgotten — protect the eye with artificial tears, ointment, and a nighttime patch, because she cannot blink and is at real risk of exposure keratitis. Most patients recover substantially within weeks. Working through the traps: a stroke spares the forehead and usually brings limb or speech findings; Ramsay Hunt syndrome is facial palsy plus painful vesicles in the ear canal or on the palate and needs antivirals; Lyme is the one to suspect in an endemic area, especially with bilateral palsy or a preceding rash; and an acoustic neuroma comes on gradually with hearing loss and tinnitus, not overnight.
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