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What is Bell's palsy?
Bell's palsy is a form of facial paralysis resulting from damage to the VIIth (facial) cranial nerve. The condition is named for Sir Charles Bell, a Scottish surgeon in Edinburgh who studied the nerve and its innervations of the facial muscles in1821. Since the function of the facial nerve is so complex, many symptoms may occur when the fibers of the facial nerve are disrupted. A disorder of the facial nerve may result in twitching, weakness or paralysis of the face, dryness of the eye or the mouth, or in disturbance of taste.
      Bell's Palsy temporarily prevents the nerve from transmitting signals to the muscles, causing weakness or paralysis. When half or one side of these individual nerve fibers are interrupted, hemi-facial weakness occurs. Rarely we see bilateral facial paralysis. If these nerve fibers are irritated, then movements of the facial muscles appear as spasms or twitching.
      It can strike almost anyone at any age. Statistics indicate that the disorder affects approximately 2 out of 10,000 people, however, the actual incidence is likely to be much higher.
       The muscles of the eyelid are supplied by the (facial) VII nerve, but the muscles that control all the eyeball movements (rectus and oblique muscles) are not. Thus, there will be difficulty in closing the eyelids, but the vision and the eyeball movements are not affected, as the optic and trochlear nerves are not involved. The taste sensations are affected, as they are carried via the facial nerve, but the tongue movements are normal. Skin sensation over the ear maybe affected with tingling sensation over the rest of the face. Chewing and swallowing actions are usually normal.

What are the causes for Bell’s palsy?
The specific cause of Bell's Palsy is unknown. A number of things can damage the facial cranial nerve and lead to Bell's palsy. Several systemic diseases can cause facial paralysis and are sometimes misdiagnosed as Bell's palsy. Most Bells Palsy are designated as idiopathic, but it is caused by an inflammation within the small bony tube called the fallopian canal (in the temporal bone), through which the nerve passes before exiting from the stylomastoid foramen. The canal is an extremely narrow area, and an inflammation within it is likely to exert pressure on the nerve. The nerve has not yet divided into its several branches thus resulting in impairment of all functions controlled by the VIIth nerve.
                 It has been suggested by various sources that it may be associated with the following:
1. Viral and Bacterial infection (about 75% of cases). Viral and Bacterial infections that are said to cause Bells Palsy are: Herpes simplex virus (HSV-1) has been identified as the most frequent cause of Bells palsy. A vast majority of the population has been exposed to HSV-1 during childhood. The active virus produces cold sores (blisters) over the body, but the virus often runs its course without causing any blisters (blisters actually appear in only 15% of the cases). HSV-1 is only infectious for a short period of time, after which it enters into a dormant state. For most people, the virus remains dormant forever. But sometimes the dormant virus are triggered into its active form. The triggers for reactivation of the virus is not known. Decreased immunity, stress, lack of sleep, minor illness, upper respiratory infection, autoimmune syndromes, chronic disease, etc has been thought to be the causative factor. When this occurs the immune system automatically begins to produce antibodies to destroy the virus, resulting in an inflammatory reaction. But the inflammation occurs in the small tight canal (fallopian canal) with no space for swelling, thus putting pressure on the nerve and compressing it. Compression of the nerve stops transmission of nerve stimuli to the facial muscles, and causes weakened or paralyzed facial muscles, resulting in Bell's palsy.
Ramsey Hunt Syndrome (RHS) is caused by Varicella Zoster virus (VSV), the same virus that causes chicken pox. Like HSV-1, it remains in the body after the initial infectious stage, residing on nerve tissue and on nerve ganglia in a dormant state. The symptom is usually the appearance of blisters in the ear, which can be expected to last 15-30 days. The blisters can appear prior to, concurrent to, or even after the onset of facial paralysis. RHS can also affect the auditory nerve (VIII Cranial nerve). It is contagious and contact with an open blister by someone who has never had chickenpox can result in transmission of the virus.
HIV can cause Bells Palsy. In the early stages of HIV, paralysis can be directly related to the viral infection, but in the later stages paralysis is mainly due to the associated opportunistic infections or tumors.
Cytomegalovirus, Epstein Barr virus etc have also been implicated as the cause for Bells Palsy.
2. Diabetes.
3. Flu-like illness, toxins. Lyme disease can cause symptoms of Bells palsy. Bacteria may enter the body through the skin at the site of the tick bite and produce flu-like symptoms. Typical early symptom of Lyme disease is a red ring around the site of the tick bite. Without an antibiotic therapy the bacteria can spread throughout the body, causing arthritis, heart disease, and nervous system disorders such as facial paralysis.
4. High blood pressure.
5. Respiratory infection (about 50% of cases).
6. Trauma, temporal bone fractures, trauma to the facial nerve etc.
7. Surgical wounds
8. Brain stem injuries.
9. Cysts and tumors.
10. Guillain-Barre syndrome.
11. Sarcoidosis.
12. Myasthenia Gravis.
13. Sjogrens syndrome.
14. Stress.
15. High winds directly onto the face.
16. Poor nutrition.
17. Dental Treatment.
18. Otitis Media. Bacteria from acute or chronic middle ear infections can invade the fallopian canal around the nerve. As with viruses, the invasion can evoke an inflammatory response, and compress the nerve.
19. Pregnancy is not a cause but it's been reported that a high number of pregnant women have been affected.
20. Venereal diseases.
21. Thyroid malfunctions.
22. Melkersson-Rosenthal syndrome.
23. Kawasaki disease.
24. Multiple sclerosis.
25. Parotitis.
26. It has also been suggested that it can be inherited or due to a congenital defect.

What are the symptoms and the problems associated with Bell’s palsy?
The VIIth Facial cranial nerve has both motor and sensory functions. Its motor functions include shutting the eye, lifting the eyebrow, and supplying the muscles that move the mouth and lips. Its sensory functions include tasting on the front of the tongue and dampening the level of the sound we hear. So the symptoms of Bell's palsy include any abnormalities involving these various muscles. Many people describe feeling a pain behind their ear or near the jaw a few days before the other symptoms develop. Symptoms begin suddenly and hit their peak usually within 48 hours. Seventy-five percent of cases are preceded by upper respiratory infection or a viral infection.

1. The most common symptom of Bell's palsy is weakness on one entire side of the face. Sudden one-sided facial paralysis or weakness of the facial muscles.
2. A person may not be able to close one eye, inability to blink, or they may have difficulty shutting their eye completely. Diminished blinking and the absence of tearing together can reduce or eliminate the flow of tears across the eyeball, resulting in drying, erosion, and ulcer formation on the cornea and possible loss of the eye.
3. The forehead doesn't wrinkle when a person tries to lift their eyebrow.
4. The lower part of the face may droop down.
5. Patients aren't able to lift their mouths to smile or fill their cheeks with air.
6. They may drool from the mouth.
7. Some people may feel a tingling, twitching or numbness in the face.
8. Face feels stiff or pulled to one side, change in facial appearance, difficulty with facial expressions, grimacing etc, difficulty with fine facial movements, asymmetrical smile.
9. Dry eyes or tearing (crocodile tears).
10. Pain in the back of the head, ear, behind the ear, or the affected side of the face.
11. Hypersensitivity to sound (hyperacusis) or hearing deficit.
12. Dry mouth and impairment of taste.
13. Difficulty with eating and drinking.
14. Speech is affected.
15. Nose feels stuffed or blocked, or runs.
16. Pain in or near the ear. Blisters in the ear.
17. Fatigue and dizziness (vertigo).
18. Tooth decay and gum disease due to reduced saliva and impairment of chewing.
19. Psychological and self-esteem problems.

What are the Diagnostic tests done?
During the clinical examination you will be asked to do various things with your face. Your doctor may ask you to lift your eyebrows and then lower them, close your eyes tightly, wrinkle your forehead, blow out your cheek, whistle etc if the two sides don't move in the same way, it suggests that one side is weaker than the other. Not being able to taste on the front of the tongue and noises sounding louder than expected are both indications of Bell's palsy. Blood pressure is checked. A skull x-ray may be done to rule-out infection or tumor. Symptoms of Bell's palsy will appear only in the face, muscle weakness in other parts of the body suggests that there is some other problem. After an examination of the head, neck, and ears, a series of tests may be performed. The most common tests are:
Hearing Test: Determines if the cause of damage to the nerve has involved the hearing nerve, inner ear, or delicate hearing mechanism.
Balance Test: Evaluates balance nerve involvement.
Tear Test: Measures the eye's ability to produce tears.
Imaging: CT (computerized tomography) or MRI (magnetic resonance imaging) determine if there is infection, tumor, bone fracture, or other abnormality in the area of the facial nerve.
Electrical Test: Stimulates the facial nerve to assess how badly the nerve is damaged. This test may have to be repeated at frequent intervals to see if the disease is progressing.
Laboratory or blood studies may be necessary to determine the underlying cause like autoimmune problems, Lyme disease or other viral infections which can lead to Bell's palsy.

What is the treatment for Bell’s palsy?
The prognosis for Bell's palsy is generally very good. With or without treatment, most patients begin to get significantly better within 2 weeks, and about 80 percent recover completely within 3 months. For some, however, the symptoms may last longer. In a few cases, the symptoms may never completely disappear. Only 1 in 10 patients never experience a complete disappearance of symptoms. The extent of nerve damage determines the extent of recovery. There is no specific treatment for Bell's palsy.

The most important part of treatment is to keep the eyes healthy and moist. One of the purposes of blinking and closing the eyes is to keep the eyes wet. If a person can't close their eyes, because the muscles that control the eyelids are paralyzed, it is important to keep the eyes moist and prevent itching. Eye drops are prescribed for the day, and an eye ointment for the night to prevent drying of the surface of the eye cornea. Diminished blinking and the absence of tearing together can reduce or eliminate the flow of tears across the eyeball, resulting in drying, erosion, and ulcer formation on the cornea and possible loss of the eye. Closing the eye with a finger is an effective way of keeping the eye moist. Use the back of the finger to ensure that the eye is not injured with the finger tip. Protective glasses or clear eye patches are often used to keep the eye moist, and to keep foreign materials from entering the eye.
      If infection is the cause, then an antibiotic to fight bacteria (as in middle ear infections) or antiviral agents (to fight syndromes caused by viruses like HSV, Ramsay Hunt) may be used. If simple swelling is believed to be responsible for the facial nerve disorder, then corticosteroids (prednisone) can be administered to relieve swelling and to prevent an early condition from getting worse. It is usually given for one week, though it shouldn't be prescribed if there are any signs of infection or other problems that are known to cause complications with short-term steroid use. A pain reliever may be necessary to relieve pain.
          Some have used electrical stimulation to stimulate the facial nerve. There is no scientific evidence of its effectiveness. Some researchers have found that electrical stimulation might have caused further nerve damage and delayed healing. Sometimes physiotherapy can be helpful in strengthening the facial muscles. Patients with Bell's Palsy should find ways to reduce the stressful situations in their lives in order to speed recovery and avoid recurrence.

Massage muscles of the forehead, cheek, lips and eyes using cream or oil. Exercise the weak muscles in front of a mirror. Open and close the eye, wink, smile and bare your teeth. Perform the massage and exercise for 15 or 20 minutes several times a day. Some patients may benefit from a special form of physical therapy called facial retraining. Brush and floss teeth more often to keep the mouth healthy.

Patients with permanent facial paralysis may be rehabilitated through a variety of surgical procedures including eyelid weights or springs, muscle transfers and nerve substitutions. Other medical treatments for complications of facial paralysis including excessive motion of the face (twitching) or muscle spasm may involve surgical division of overactive muscles or weakening them by chemical injection. In certain circumstances, surgical removal of the bone around the nerve (decompression) may be done.

What is Residual Effects (Synkinesis)?
People usually recover completely from Bells Palsy. Generally the regeneration of nerves will be complete within three months after onset. If recovery is delayed by more than three months then sometimes you may begin to notice movements in areas of the face that you are not even trying to move. This is referred to as Residual Effects (Synkinesis). When you smile the eye may close or twitch, or when you close you eye the corner of your mouth may pull up or out to the side. Residual effects is seen only in cases where recovery from Bell's palsy is delayed beyond the 3 months. The longer the recovery takes beyond the initial three months, the more severe the residual effects. It is characterized by uncoordinated or unsynchronized facial movements that occur along with normal movements. Synkinesis varies in severity from mild to severe.
                          Synkinesis is theorized to be the effect of abnormal nerve regeneration. Within the main trunk of the facial nerve are between 6000-7000 different, very delicate, very thin, frail nerve fibers that conduct the electrical signal from the brain to the facial muscles. Inflammation within the canal can cause damage to some of these very frail fibers. In time these damaged nerve fibers regenerate (at the rate of about 1-2mm per day). But there's no mechanism that directs these fibers back into their original muscles. Some of the healing nerve fibers may implant themselves into the wrong muscles. The brain sends the signal for the muscle to contract thinking the nerve fiber is still connected to the original muscle, but instead, the nerve may be lodged in an entirely different muscle, resulting in movement of a completely different muscle. The affected side of the face may feel tight as the result of the uncontrolled muscle contractions (spasms).

Treatment for residual Synkinesis can be effective at any time after it is noticed. The focus of the treatment is on re-coordinating the various muscles rather than stimulating them. We know that when Synkinesis is present the facial muscles are viable, or "alive". Even an abnormal movement is still a movement. It is possible to restore more normal movement patterns and expression with specific, appropriate training through physiotherapy.

Conclusion
Disorders of the facial nerve, including paralysis, are not rare and can be due to a variety of causes. The appropriate diagnosis and treatment are very important to achieving the best possible recovery of facial nerve function. Even patients with permanent facial nerve injury can be helped by surgical procedures designed to improve facial function. Considerable attention must be given to maintaining a healthy eye, which requires a constant flow of tears. Brush and floss teeth more often to keep the mouth healthy. Bell's palsy is distressing, but it is not dangerous. The disorder is not a threat to life. Most people do not have a recurrence, however, some do.

Some Facts:
1.  It is an "equal opportunity" disease. The percentage of left or right side cases is approximately equal, and remains equal for recurrences.
2.  The incidence of Bell's palsy in males and females, as well as in the various races is also approximately equal.
3.  Older people are more likely to be afflicted, but children are not immune to it. Children tend to recover well.
4.  Diabetics are more than 4 times more likely to develop Bells Palsy than the general population.
5.  Conditions that compromise the immune system such as HIV increase the odds of facial paralysis occurring and recurring.
6.  Bilateral Bell's palsy is rare, accounting for less than 1% of cases.
7.  The degree of paralysis should peak within several days of onset, usually never longer than 2 weeks (3 weeks max for RHS).
8.  The nerve regenerates at a rate of approximately 1 millimeter per day.
9.  Approximately 50% of Bells Palsy patients will have essentially complete recoveries in a short time. Another 35% will have good recoveries in less than a year.
10. The nerve can continue to regenerate for 18 months, probably even longer. Improvement of appearance can continue beyond that time frame.
11. The possibility of recurrence had been thought to be as high as 10 - 20%. These figures have been lowered as more has been learned about the types of facial paralysis that are now known to be other than Bell's palsy. Estimates of the rate of recurrence still vary widely, from around 4 - 14%.
12. The muscles that close the eyelid are controlled by VII nerve, but the muscles that control other eye movements and the ability to focus are not. There will be difficulty in closing the eyelids, but other functions and movement of the eye is not affected. The sense of taste is affected, but tongue motion is not. Skin sensation may be affected near the ear, but sensation over the rest of the face usually remains normal. Chewing and swallowing are not affected.
13. Various viral infections (herpes, Lyme disease, mumps, tuberculosis, HIV, etc), tumors, bony abnormalities, a skull fracture or any other trauma, surgery, neurological dysfunction (diabetes), various neurological disorders (Guillain-Barre syndrome, myasthenia gravis, etc), micro-circulation problems, etc can lead to facial palsy.
14. Bell's palsy and Ramsey Hunt syndrome can be bilateral, but it's rare. Mononucleosis, flu, Guillain-Barre Syndrome, Leukemia, Lyme disease, Sarcoidosis and Heerdfort's Syndrome can be potential triggers of bilateral palsy.
15. Residual effects can be present in cases where recovery from Bell's palsy is delayed beyond the 3 months period.