Bell's palsy natural history, complications and prognosis

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

Overview

If left untreated, [#]% of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].

OR

Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].

OR

Prognosis is generally excellent/good/poor, and the 1/5/10-year mortality/survival rate of patients with [disease name] is approximately [#]%.

Natural History, Complications, and Prognosis

Natural History

• The onset of Bell's palsy is sudden and symptoms typically peak fast, within a few days and include:
• the main symptom is acute peripheral facial weakness.
• Additional symptoms may include:
  • Pain in or behind the ear
  • Numbness or tingling in the affected side of the face usually without any objective deficit on neurological examination
  • Hyperacusis and disturbed taste on the ipsilateral anterior part of the tongue

Complications

• Complications of Bell’s palsy include:
  • Incomplete eyelid closure with resultant dry eye
  • Permanent facial weakness with muscle contractures
  • Motor synkinesis (involuntary movement of muscles occurring at the same time as deliberate movement, e.g. involuntary mouth movement during voluntary eye closure)
  • Crocodile tears (tears when eating due to misdirection of regenerating gustatory fibres destined for the salivary glands, so that they become secretory fibres to the lacrimal gland and cause ipsilateral tearing while the patient is eating)
  • Incomplete recovery
  • Contracture of facial muscles
  • Reduction or loss of taste sensation
  • Problems with dysarthria due to facial muscle weakness

Prognosis

• Prognosis is generally good.
• If left untreated approximately 71% of patients with Bell's palsy recover normal function and around 13% are left with slight weakness and around 4% with severe weakness resulting in major facial dysfunction.
• The presence of complete palsy, advanced age and Herpes zoster infection is associated with a particularly poor prognosis among patients with Bell's palsy.

Natural History, Complications and Prognosis

• The House-Brackmann grading system was devised both as a clinical indicator of severity and also an objective record of progress.
• Clinically incomplete lesions tend to recover.
• The natural history without treatment was described in a study of 1011 patients in 1982:

• 67% had incomplete paralysis, with 94% rate of return to normal function
• 33% had complete paralysis, with 60% rate of return to normal function
• By 3 weeks, 71% had complete recovery, 13% had slight sequelae , and 16% had residual weakness

• Herpes zoster is associated with more severe paresis and worse prognosis compared with "idiopathic" Bell's palsy.
• There is a favorable prognosis if some recovery is seen within the first 21 days of onset.
• In severe lesions that recover, the outgrowth of new axons from the injury site may be disorganized and misdirected.
• On blinking there is twitching of the angle of the mouth, and on smiling the eye may close or wink.
• With misdirected autonomic fibers, a salivary stimulus may result in excess lacrimation, the syndrome of "crocodile tears."
• Recurrent attacks on either the ipsilateral or contralateral side have been observed in 7 to 15% of patients.