Bell’s Plays is a lower motor neurone (LMN) lesion of the facial nerve (CN VII), which causes one side of the face to “droop” [1% of cases are bilateral], and patients are often concerned that it is a stroke.

However, unlike in stroke the whole face is affected, in stroke and other upper motor neurone (UMN) lesions the upper portion of the face is unaffected due to input from both sides of the brain.

Signs & Symps

• Facial weakness: affecting both upper and lower portions of face (i.e. can only raise eyebrow and frown on one side)
• Decreased lacrimation and salivation
• Loss of taste: facial nerve controls anterior 2/3 of tongue
• Dysacusis: sensitivity to loud sounds as stapedial muscles affected (rare)

Important differentials to exclude

• Ramsy Hunt: Herpes zoster infection, shingles type rash in ear canal, will need acyclovir and ENT input.
• Lyme’s disease: Is spreading across europe. Ask about tick bites, erythema marginatum (rash), typically treated with doxycycline, and will need Infectious disease follow up. NICE

Management

NICE recommend following: NICE

• Steroids: either as no consensus currently
  • Prednisolone 25mg BD, 10 days
  • Prednisolone 60mg OD, 5 days, then reduce by 10mg a day (total course 10 days)
• No Antivirals
• Eye lubrication:
  • Eye drops in day
  • Ointment at night
  • Tape eye with micropore tape at night if not closing
• GP follow up: to monitor recovery
• Specialist Referral: to ENT or neurology only if unsure of diagnosis, recurrent, or bilateral

Prognosis

• Resolution: 71% full recovery, only 12% classified as moderate and 4% poor
• Speed of recovery: recovery starts within 3 weeks for most with full recovery at 6-12 months
• Complications: 9% can have spasms, contractures, tinitus, hearing loss, crocodile tears(crying on salivation)

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