Bell Palsy Differential Diagnoses

  • Author: Danette C Taylor, DO, MS; Chief Editor: B Mark Keegan, MD, FRCPC   more...
 
Updated: Apr 11, 2012
 
 

Diagnostic Considerations

In most cases, the diagnosis of Bell palsy is straightforward as long as the patient has undergone a thorough history and physical examination. Failure to recognize structural, infectious, or vascular lesions leading to seventh cranial nerve (facial nerve) damage may result in further deterioration of the patient’s condition. For example, if other cranial nerve, motor, or sensory symptoms were present, then treatable or preventable nervous system diseases should be sought (eg, stroke, Guillain-Barré syndrome [GBS], basilar meningitis, or cerebellar pontine angle tumor).

Symptoms associated with seventh nerve neoplasm include slowly progressive paralysis, facial hyperkinesis, severe pain, recurrent palsy, and other cranial nerve involvement. Cerebellopontine tumors may affect the seventh, eighth, and fifth cranial nerves simultaneously. Patients with a progressive paralysis of the facial nerve lasting longer than 3 weeks should be evaluated for neoplasm.

Recurrent ipsilateral facial paralysis must raise the suspicion of a tumor of the facial nerve or parotid gland. Tumors in the temporal bone such as facial nerve neuromas, meningiomas, hemangiomas, and malignant primary and metastatic lesions should be considered as well.

If a patient is from the Northeast, Lyme disease should be considered as a cause of facial paralysis, and serologic testing should be performed. Approximately 5-10% of untreated Lyme patients may have a peripheral facial nerve palsy.

If the patient reports sudden onset of hearing loss and severe pain with the onset of facial paralysis, Ramsay Hunt syndrome must be considered.

Other problems to be considered include the following:

  • Acoustic neuroma and other cerebellopontine angle lesions
  • Acute or chronic otitis media
  • Amyloidosis
  • Aneurysm of vertebral, basilar artery, or carotid arteries
  • Autoimmune syndromes
  • Botulism
  • Carcinomatosis
  • Carotid disease and stroke, including embolic phenomenon
  • Cholesteatoma of the middle ear
  • Congenital malformation
  • Diabetes mellitus
  • Facial nerve schwannoma
  • Geniculate ganglion infection
  • Glomus tumors
  • Guillain-Barré syndrome
  • Herpes zoster
  • HIV
  • Leukemia/lymphoma
  • Leukemic meningitis
  • Lyme disease
  • Malignant otitis externa
  • Melkersson-Rosenthal syndrome
  • Meningitis
  • Mycoplasma pneumonia
  • Nasopharyngeal carcinoma
  • Osteomyelitis of the skull base
  • Otitis media
  • Parotid gland disease or tumor
  • Pontine lesions
  • Pregnancy (especially third trimester)
  • Ramsay Hunt syndrome
  • Sarcoma
  • Skull base tumor
  • Teratoma
  • Tuberculosis
  • Viral syndromes
  • Wegener granulomatosis
  • Wegener vasculitis

In the setting of an appropriate history, additional considerations include the following:

  • Alcoholic neuropathy
  • Anesthesia nerve blocks
  • Basal skull fractures
  • Barotrauma
  • Benign intracranial hypertension
  • Birth trauma
  • Carbon monoxide exposure
  • Diphtheria
  • Facial injuries
  • Facial trauma (blunt, penetrating, iatrogenic)
  • Forceps delivery
  • Iatrogenic (as in otologic, neurotologic, skull base, or parotid surgery)
  • Infectious mononucleosis
  • Kawasaki disease
  • Leprosy
  • Metastatic disease
  • Mumps
  • Polyneuritis
  • Temporal bone fracture
  • Tetanus
  • Thalidomide exposure
  • Toxic

Differential Diagnoses

Proceed to Workup
 
 
Contributor Information and Disclosures
Author

Danette C Taylor, DO, MS  Clinical Assistant Professor, Department of Neurology, Michigan State University College of Osteopathic Medicine; Senior Staff Neurologist, Henry Ford Health Systems

Danette C Taylor, DO, MS is a member of the following medical societies: American Academy of Neurology, American Medical Association, American Osteopathic Association, and Movement Disorders Society

Disclosure: Allergan Honoraria Speaking and teaching

Coauthor(s)

Suzan Khoromi, MD  Fellow, Pain and Neurosensory Mechanisms Branch, National Institute of Dental and Cranial Research, National Institutes of Health

Suzan Khoromi, MD is a member of the following medical societies: American Academy of Neurology, American Pain Society, and International Association for the Study of Pain

Disclosure: Nothing to disclose.

Kim Monnell, DO  Neurology Consulting Staff, Department of Medicine, Bay Pines VA Medical Center

Kim Monnell, DO, is a member of the following medical societies: American Academy of Neurology and American Osteopathic Association

Disclosure: Nothing to disclose.

Sally B Zachariah, MD  Associate Professor, Department of Neurology, University of South Florida College of Medicine; Director, Department of Neurology, Division of Strokes, Veteran Affairs Medical Center of Bay Pines

Sally B Zachariah, MD is a member of the following medical societies: American Academy of Neurology, American Heart Association, and American Society of Neuroimaging

Disclosure: none None None

Chief Editor

B Mark Keegan, MD, FRCPC  Assistant Professor of Neurology, College of Medicine, Mayo Clinic; Master's Faculty, Mayo Graduate School; Consultant, Department of Neurology, Mayo Clinic, Rochester

B Mark Keegan, MD, FRCPC is a member of the following medical societies: American Academy of Neurology, American Medical Association, and Minnesota Medical Association

Disclosure: Novartis Consulting fee Consulting; Bionest Consulting fee Consulting

Additional Contributors

Edward Bessman, MD Chairman, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University School of Medicine

Edward Bessman, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Dominique Dorion, MD, MSc, FRCSC, FACS Vice Dean and Associate Dean of Resources, Professor of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Sherbrooke Faculty of Medicine, Canada

Disclosure: Nothing to disclose.

Thomas R Hedges III, MD Director of Neuro-Ophthalmology, New England Eye Center; Professor, Departments of Neurology and Ophthalmology, Tufts University School of Medicine

Thomas R Hedges III, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Medical Association, and North American Neuro-Ophthalmology Society

Disclosure: Nothing to disclose.

J Stephen Huff, MD Associate Professor, Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia Health Sciences Center

J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Milind J Kothari, DO Professor and Vice-Chair, Department of Neurology, Pennsylvania State University College of Medicine; Consulting Staff, Department of Neurology, Penn State Milton S Hershey Medical Center

Milind J Kothari, DO is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, and American Neurological Association

Disclosure: Nothing to disclose.

Andrew W Lawton, MD Medical Director of Neuro-Ophthalmology Service, Section of Ophthalmology, Baptist Eye Center, Baptist Health Medical Center

Andrew W Lawton, MD is a member of the following medical societies: American Academy of Ophthalmology, Arkansas Medical Society, and Southern Medical Association

Disclosure: Nothing to disclose.

Bruce Lo, MD Medical Director, Sentara Norfolk General Hospital; Assistant Professor, Assistant Program Director, Core Academic Faculty, Department of Emergency Medicine, Eastern Virginia Medical School

Bruce Lo, MD is a member of the following medical societies: American College of Emergency Physicians, Emergency Medicine Residents Association, Medical Society of Virginia, Norfolk Academy of Medicine, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Arlen D Meyers, MD, MBA Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society

Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation Unrestricted gift Unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo Consulting; Medvoy Ownership interest Management position; Cerescan Imaging Honoraria Consulting; GYRUS ACMI Honoraria Consulting

Hampton Roy Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Reference Salary Employment

Florian P Thomas, MD, MA, PhD, Drmed Director, Spinal Cord Injury Unit, St Louis Veterans Affairs Medical Center; Director, National MS Society Multiple Sclerosis Center; Director, Neuropathy Association Center of Excellence, Professor, Department of Neurology and Psychiatry, Associate Professor, Institute for Molecular Virology, and Department of Molecular Microbiology and Immunology, St Louis University School of Medicine

Florian P Thomas, MD, MA, PhD, Drmed is a member of the following medical societies: American Academy of Neurology, American Neurological Association, American Paraplegia Society, Consortium of Multiple Sclerosis Centers, and National Multiple Sclerosis Society

Disclosure: Nothing to disclose.

B Viswanatha, MBBS, MS, DLO Professor of Otolaryngology (ENT), Chief of ENT III Unit, Sri Venkateshwara ENT Institute, Victoria Hospital, Bangalore Medical College and Research Institute; PG and UG Examiner, Manipal University, India and Annamalai University, India

B Viswanatha, MBBS, MS, DLO is a member of the following medical societies: Association of Otolaryngologists of India, Indian Medical Association, and Indian Society of Otology

Disclosure: Nothing to disclose.

Brian R Younge, MD Professor of Ophthalmology, Mayo Clinic School of Medicine

Brian R Younge, MD is a member of the following medical societies: American Medical Association, American Ophthalmological Society, and North American Neuro-Ophthalmology Society

Disclosure: Nothing to disclose.

Craig H Zalvan, MD Director of Laryngology, Assistant Professor of Otolaryngology, Head and Neck Surgery, Department of Otorhinolaryngology-Head and Neck Surgery, ENT Faculty Practice

Craig H Zalvan, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Bronchoesophagological Association, American College of Surgeons, American Laryngological Association, American Laryngological Rhinological and Otological Society, American Medical Association, Medical Society of the State of New York, New York County Medical Society, Triological Society, and Voice Foundation

Disclosure: Nothing to disclose.

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The facial nerve.
Left-sided Bell palsy.
 
 
 
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