Pontine stroke mimicking Bell’s palsy: a cautionary tale!

Stroke has been called apoplexy since the ancient times of Babylonia. Johann Jakob Wepfer, a Swiss physician, first described the aetiology, clinical features, pathogenesis and postmortem features of an intracranial haemorrhage in 1655. Haemorrhagic and ischaemic strokes are the two subtypes of stroke. Bell’s palsy usually presents with an isolated facial nerve palsy. A lacunar infarct involving the lower pons is a rare cause of solitary infranuclear facial paralysis. The authors present the case of a 66-year-old woman presenting with a 3-day history of headache, vertigo, nausea, vomiting and facial weakness. Her comorbidities included diabetes, hypertension and hypercholesterolaemia. It was challenging to identify the pontine infarct on MRI due to its small size and the confounding presentation of complete hemi-facial paralysis mimicking Bell’s palsy. Our case provides a cautionary reminder that an isolated facial palsy should not always be attributed to Bell’s palsy, but can be a presentation of a rare dorsal pontine infarct as observed in our case. Anatomic knowledge is crucial for clinical localisation and correlation.

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Rehabilitation of a Patient with Bell’s Palsy

Journal of Evolution of Medical and Dental Sciences ◽

10.14260/jemds/2021/323 ◽

2021 ◽

Vol 10 (20) ◽

pp. 1551-1554

Author(s):

Vrushali K. Athawale ◽

Dushyant P. Bawiskar ◽

Pratik Arun Phansopkar

Keyword(s):

Herpes Simplex ◽

Facial Nerve ◽

Facial Paralysis ◽

Nerve Palsy ◽

Facial Nerve Palsy ◽

Bell’S Palsy ◽

Pharmacological Therapy ◽

Bell's Palsy ◽

Facial Reanimation ◽

Simplex Virus

Facial nerve palsy is the disease of cranial nerve. From the total number of cases, 60 to 75 % of Bell's palsy cases are idiopathic form of facial palsy. Facial nerve palsy results in weakness of facial muscles, atrophy, asymmetry of face and also disturbs the quality of life. Bell’s palsy occurs in every class of population affecting people of all the age groups but the most common age group affected is 15 - 50 years with equal sex prediliction accounting 11 - 40 cases per 100,000. If facial palsy is not treated properly then it may result in variety of complications like motor synkinesis, dysarthria, contractures of facial muscles, and crocodile tear. Currently facial paralysis treatment consists of combination of pharmacological therapy, facial neuromuscular re-entrainment physiotherapy or surgical intervention by static and dynamic facial reanimation techniques. Physiotherapy treatment is effective for treating facial paralysis with minimal complications and can be individualized. Bell's palsy is the idiopathic form of facial nerve palsy which accounts for 60 to 75 % of cases and male to female ratio is 1:3.1 The aetiology of facial paralysis is not yet thoroughly understood. Cases of varicella-zoster, mononucleosis, herpes simplex virus, mumps and measles have demonstrated good serology in several reports for their association but still stands unclear. 2 Peripheral facial nerve palsy may be idiopathic (primary cause) or Bell’s palsy (secondary). Causes of the secondary unilateral facial nerve palsy are diabetes, stroke, Hansen's disease, herpes simplex infection, birth injury, trauma, tumour, Guillain-Barre syndrome, and immune system disorders. Causes of the bilateral facial nerve palsy are leukemia, brainstem encephalitis, leprosy, and meningitis. The most prominent current theories of facial nerve paralysis pathophysiology include the reactivation of herpes simplex virus infection (HSV type 1). Current facial paralysis treatment consists of a combination of pharmacological therapy, facial neuromuscular re-entrainment physiotherapy or surgical intervention by dynamic and static facial reanimation techniques.7 This is a diagnosed case of right facial nerve palsy which was treated under physiotherapy department with proper rehabilitation protocol.

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Medial Pontomedullary Stroke Mimicking Severe Bell’s Palsy: A Case Report

Clinical Practice and Cases in Emergency Medicine ◽

10.5811/cpcem.2020.5.46965 ◽

2020 ◽

Vol 4 (3) ◽

pp. 380-383

Author(s):

Benjamin Boodale ◽

Manish Amin ◽

Katayoun Sabetian ◽

Daniel Quesada ◽

Tyler Torrico

Keyword(s):

Case Report ◽

Rare Case ◽

Bell’S Palsy ◽

Facial Weakness ◽

Bell's Palsy ◽

Sensory Deficits ◽

Contralateral Motor ◽

Pontomedullary Junction ◽

Gaze Palsy ◽

Pontine Infarct

Introduction: Patients with acute unilateral upper and lower facial palsy frequently present to the emergency department fearing they have had a stroke, but many cases are benign Bell’s palsy. Case Report: We present a rare case of a medial pontomedullary junction stroke causing upper and lower hemifacial paralysis associated with severe dysphagia and contralateral face and arm numbness. Conclusion: Although rare, pontine infarct must be considered in patients who present with both upper and lower facial weakness. Unusual neurologic symptoms (namely diplopia, vertigo, or dysphagia) and signs (namely gaze palsy, nystagmus, or contralateral motor or sensory deficits) should prompt evaluation for stroke.

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Inherited Bell's Palsy

Annals of Otology Rhinology & Laryngology ◽

10.1177/000348947408300309 ◽

1974 ◽

Vol 83 (3) ◽

pp. 343-346 ◽

Cited By ~ 21

Author(s):

Jeffrey W. Willbrand ◽

Joel D. Blumhagen ◽

Mark May

Keyword(s):

Family History ◽

Facial Paralysis ◽

Autosomal Dominant ◽

Positive Family History ◽

Bell’S Palsy ◽

Autosomal Dominant Inheritance ◽

Single Family ◽

Dominant Inheritance ◽

Bell's Palsy ◽

History Of

Twenty-nine cases of Bell's palsy in a single family appear to suggest an autosomal dominant inheritance. In addition, a review of 230 consecutive patients with Bell's palsy revealed a 6% incidence of a positive family history of facial paralysis. These findings implicate inheritance in the etiology of Bell's palsy.

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Sequential contralateral facial nerve palsies following COVID-19 vaccination first and second doses

BMJ Case Reports ◽

10.1136/bcr-2021-243829 ◽

2021 ◽

Vol 14 (7) ◽

pp. e243829

Author(s):

Abigail Burrows ◽

Theo Bartholomew ◽

James Rudd ◽

David Walker

Keyword(s):

Emergency Department ◽

Facial Nerve ◽

Nerve Palsy ◽

Facial Nerve Palsy ◽

Case Reports ◽

Bell’S Palsy ◽

First Episode ◽

Bell's Palsy ◽

First Case ◽

History Of

A 61-year-old man presented to the ENT emergency clinic with a history of unilateral facial nerve palsy occurring shortly after each dose of the Pfizer-BioNTech COVID-19 vaccine. The first episode developed 5 hours after administration of the first dose and the second 2 days after administration of the second dose. Investigations at initial presentation to the emergency department were unremarkable, and the patient was diagnosed with Bell’s palsy on both occasions. We describe the first case of Bell’s palsy occurring after each dose of any UK-approved COVID-19 vaccine. Single episodes of unilateral facial nerve palsies have been reported in clinical trials and in subsequent case reports. There has been no evidence, however, of an episode after each dose. We also describe the earliest onset of symptoms from timing of administration of the vaccine, further suggesting the Bell’s palsy was associated with the vaccine.

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Prevalence of concurrent diabetes mellitus and idiopathic facial paralysis (Bell's palsy)

Diabetes ◽

10.2337/diabetes.24.5.449 ◽

1975 ◽

Vol 24 (5) ◽

pp. 449-451 ◽

Cited By ~ 12

Author(s):

K. Adour ◽

J. Wingerd ◽

H. E. Doty

Keyword(s):

Diabetes Mellitus ◽

Facial Paralysis ◽

Bell’S Palsy ◽

Bell's Palsy

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Subacute Sclerosing Panencephalitis manifesting as Bell’s palsy and bilateral macular necrotizing retinitis: an atypical presenting feature

Journal of Ophthalmic Inflammation and Infection ◽

10.1186/s12348-020-00223-1 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Lagan Paul ◽

Tanya Jain ◽

Manisha Agarwal ◽

Shalini Singh

Keyword(s):

Subacute Sclerosing Panencephalitis ◽

Clinical History ◽

Neurological Complications ◽

Bell’S Palsy ◽

Ocular Involvement ◽

Bell's Palsy ◽

Diagnostic Challenge ◽

Bladder Control ◽

Mri Brain ◽

History Of

Abstract Background Subacute sclerosing panencephalitis (SSPE) is a potentially lethal complication of measles infection. Neurological complications take years to manifest after primary viral infection of brain and can lead to blindness in some individuals. Findings A 13-year-old female patient with history of Bell’s palsy 2 months prior, presented with rapidly progressing necrotizing retinitis in both eyes. Soon after, she was unable to walk, developed myoclonic jerks, altered sensorium and loss of bowel and bladder control. Her clinical history, CSF IgG measles antibody analysis, MRI brain and EEG findings confirmed the diagnosis of SSPE. Conclusion SSPE in our case presented as Bell’s palsy and sudden painless diminution of vision due to ocular involvement, and developed full blown disease within 2 months. SSPE can present as a diagnostic challenge and warrants early identification and referral for timely diagnosis and management.

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Facial Nerve Paralysis Induced by Herpes Simplex Virus in Mice: An Animal Model of Acute and Transient Facial Paralysis

Annals of Otology Rhinology & Laryngology ◽

10.1177/000348949510400713 ◽

1995 ◽

Vol 104 (7) ◽

pp. 574-581 ◽

Cited By ~ 80

Author(s):

Toshiaki Sugita ◽

Yasuo Fujiwara ◽

Shingo Murakami ◽

Yoshinari Hirata ◽

Naoaki Yanagihara ◽

...

Keyword(s):

Herpes Simplex Virus ◽

Herpes Simplex ◽

Facial Nerve ◽

Facial Paralysis ◽

Bell’S Palsy ◽

Facial Nerve Paralysis ◽

Bell's Palsy ◽

Vacuolar Degeneration ◽

Nerve Paralysis ◽

Simplex Virus

We have been the first to succeed in producing an acute and transient facial paralysis simulating Bell's palsy, by inoculating herpes simplex virus into the auricles or tongues of mice. The KOS strain of the virus was injected into the auricle of 104 mice and the anterior two thirds of the tongue in 30 mice. Facial paralysis developed between 6 and 9 days after virus inoculation, continued for 3 to 7 days, and then recovered spontaneously. The animals were painlessly sacrificed between 6 and 20 days after inoculation for histopathologic and immunocytochemical study. Histopathologically, severe nerve swelling, inflammatory cell infiltration, and vacuolar degeneration were manifested in the affected facial nerve and nuclei. Herpes simplex virus antigens were also detected in the facial nerve, geniculate ganglion, and facial nerve nucleus. The pathophysiologic mechanisms of the facial paralysis are discussed in light of the histopathologic findings, in association with the causation of Bell's palsy.

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Aetiological Profile of Facial Nerve Palsy Seen in Nigerian Tertiary Hospital

International Journal of Innovative Research in Medical Science ◽

10.23958/ijirms/vol05-i06/877 ◽

2020 ◽

Vol 5 (06) ◽

Author(s):

Gabriel Toye Olajide ◽

Waheed Atilade Adegbiji ◽

Akinwale Olaleye Akinbade ◽

Anthony Oyebanji Olajuyin ◽

Paul Olowoyo

Keyword(s):

Facial Nerve ◽

Nerve Palsy ◽

Facial Nerve Palsy ◽

Road Traffic ◽

Neck Region ◽

Bell’S Palsy ◽

Facial Nerve Paralysis ◽

Bell's Palsy ◽

Female Ratio ◽

Nerve Paralysis

Background/Aim: Facial nerve palsy may cause facial asymmetry, functional and cosmetic impairment, and therefore imposes great psychological and social problems on the individual with the condition. The aim of this paper was to highlight the aetiological profile of facial nerve palsy (FNP) in two tertiary institutions in Ekiti, southwest, Nigeria. Methods: This was a retrospective review of patients with facial nerve palsy seen and treated at Ear, Nose & Throat (ENT) clinic. All folders and registers of patients diagnosed with facial nerve palsy from January 2010 to December 2019 in the central, ENT and Dental medical records departments were retrieved and reviewed. The information extracted included the socio-demographic characteristics of the patients, clinical presentation, type and aetiology of FNP, side affected, diagnosis/impression, nature of impairment, type of lesion, onset of the disease, treatment and outcome. Results: Of 76 patients analysed, 48(63.2%) were males and 28(36.8%) were females given a male to female ratio of 1:1.7. Their age ranged between 5 to 72 years with a mean of 39.83 ± 17.58 SD. The age range 21-40 years was most commonly affected, representing 31 (40.8%). The commonest cause of facial nerve paralysis was Bell’s palsy in 32(42.1%), followed by trauma 28(36.9%). Of the 28 (36.9%) that was caused by trauma, road traffic injury constituted 15(53.6%). Half (50.0 %) of the lesion affected right side of the face. Seventy (92.1%) was treated medically. Majority (37.0%) presented within one week of their symptoms. All the patients presented with deviation of mouth, followed by inability to close eye in 70 (92.1%). Higher proportion (88.2%) of our patients had lower motor neuron lesion. Conclusion: This study found that majority of our patients was young adults. Bell’s palsy was a major cause of facial nerve paralysis followed by trauma. Most of our patient presented early and did well on conservative treatment. High index of suspicion is essential especially when patients present with injuries involving head and neck region.

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