Acute Facial Palsy

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Question 1 of 10

1. Question
When considering the presentation of Bell’s palsy to the emergency department (ED), which one of the following statements is correct?
- Bell's palsy is defined as an acute idiopathic upper motor neurone facial paresis
- An average sized UK ED will see approximately 500 cases of Bell's palsy per year
- More than 75% of patients with Bell's palsy will recover fully without treatment
- Motor synkinesis is a recognised complication of Bell's palsy and crocodile tears syndrome is one example of this phenomenon
- Bell's palsy can be diagnosed once a central cause for facial weakness has been excluded
Question 2 of 10

2. Question
Which one of the following statements is correct regarding the anatomy of the facial nucleus and nerve?
- The facial nuclei are innervated bilaterally by corticobulbar fibres
- The chorda tympani carries secretomotor fibres to the lacrimal glands
- Bell's palsy affecting the nerve to stapedius results in deafness of the affected ear
- There are six main branches of the facial nerve supplying the facial muscles
- The geniculate ganglion lies within the parotid gland
Question 3 of 10

3. Question
A 43-year-old man presents to the ED stating that his wife has noticed that the right side of his face is drooping. You start the assessment of this patient by taking a thorough history.

One of the following statements regarding the history is correct, which one is it?
- Facial pain is very rare in Bell's palsy and if present, an alternative diagnosis must be considered
- Altered taste will be reported by the vast majority of patients with Bell's palsy
- A history of sarcoidosis is not relevant in this case
- A sensation of facial numbness on the side of the weakness is commonly reported in Bell's palsy
- A history of fever would point towards a diagnosis of Bell's palsy
Question 4 of 10

4. Question
You move on to examine the patient. Initially you consider whether you are dealing with an upper or lower motor neurone lesion and conduct a general examination.

Which one of the following statements is correct?
- Identification of the rash of erythema marginatum would point to Lyme disease being the cause of the facial palsy
- Facial muscle weakness, including the forehead muscles, indicates an upper motor neurone lesion
- A patient with Bell's palsy will often have mildly deranged vital signs, such as a slightly raised heart or respiratory rate
- Checking the capillary blood sugar is unnecessary as previously undiagnosed diabetes cannot present with a facial palsy
- If the patient cannot close his eye tightly, there is a peripheral cause for the palsy
Question 5 of 10

5. Question
Having established that the patient has a right-sided peripheral facial weakness, you decide to examine his head and face carefully and consider which investigations may be required.

Which one of the following statements is correct regarding your examination and investigation?
- Erythema of the skin behind the right ear may be a sign of Ramsay Hunt syndrome
- Parotid tumours may compress the facial nerve as it passes through the deep lobe of the parotid gland
- Serological tests for rising antibody levels to herpes simplex should be taken routinely as they are very reliable in Bell's palsy
- The head should be examined for signs of recent trauma as delayed facial nerve paralysis may occur, usually 2-3 weeks after the injury
- The presence of otitis media on examination of the right ear would not be of any relevance
Question 6 of 10

6. Question
You confidently make a diagnosis of Bell’s palsy in a 53-year-old woman with a peripheral facial weakness of no apparent cause. Your next decision is how to treat her.

Which one of the following options is correct regarding the pharmacological management of this patient?
- There is no good evidence for the use of steroids in Bell's palsy
- Antiviral agents have been shown to improve outcome in Bell's palsy
- If her symptoms have been present for more than three days, pharmacological treatment is unlikely to be beneficial
- Prednisolone 50 mg once daily for 10 days will increase this patient's chances of a complete recovery
- A combination of prednisolone 50 mg and aciclovir for 10 days is the treatment associated with the best outcome in this patient
Question 7 of 10

7. Question
Having decided on the appropriate pharmacological management for this patient, you realise that she also needs additional advice and treatment for the complications of facial muscle weakness.

Which one of the following statements is correct?
- All patients with Bell's palsy should be prescribed steroid eye drops to prevent ocular complications
- There is strong evidence that acupuncture is beneficial in Bell's palsy
- The patient should be referred acutely to a physiotherapist for facial exercises
- Electrical stimulation of facial muscles is of proven benefit in Bell's palsy
- The affected eye should be taped shut at night to prevent exposure keratitis
Question 8 of 10

8. Question
Your patient with Bell’s palsy then asks you about follow-up and what her chances are of a full recovery.

Which one of the following statements is correct?
- Impairment of taste is a prognostic indicator that predicts a better outcome
- A history of hypertension is a poor prognostic indicator
- Follow-up of Bell's palsy patients is unnecessary as the majority will recover completely
- The older the patient the better the prognosis
- In general, a patient with grade VI weakness on the House-Brackmann classification will do better than one on with a grade I weakness
Question 9 of 10

9. Question
Which one of the following statements is correct regarding the pathophysiology and clinical presentation of a patient with Ramsay Hunt syndrome?
- Herpes simplex is the organism responsible for Ramsay Hunt syndrome
- The patient does not require any further infection control advice
- Facial weakness with vesicles on the contralateral side of the tongue is a diagnostic feature
- Ramsay Hunt syndrome causes an upper motor neurone weakness of the facial muscles
- The rash may be present on the side of the neck
Question 10 of 10

10. Question
A 58-year-old woman presents to the ED with a left sided facial weakness of 6 hours duration. She is previously fit and well and is not taking any medication. She has felt systemically well, has no other symptoms and no abnormal signs on general examination.

Which one of the following statements is correct regarding your assessment and management of this patient?
- If no rash is seen, then Ramsay Hunt syndrome can be completely excluded
- If Bell's palsy is diagnosed, there is a high chance of recurrence in the future
- In the presence of a vesicular rash in the left ear canal, a combination of high dose prednisolone and aciclovir is the optimal pharmacological treatment for this patient
- Serological tests for Lyme disease are mandatory in this patient
- Zoster sine herpete is a term describing Bell's palsy in association with herpes labialis

3 Comments

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Dr Hafeez Dayo Owonifari September 4, 2023 at 1:52 am

A wonderful teaching

Dr Syed Shahbaz Ahmer March 5, 2024 at 12:56 pm

Great learning

Dr Karen Elizabeth Sutherland, Specialty doctor May 12, 2025 at 9:04 pm

Excellent module

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