Case history
Case history
A 40-year-old woman awakens with left-sided facial fullness and a subjective feeling of facial and tongue "numbness" without objective hypoesthesia. She also notes left-sided dysgeusia. Later that day, she develops left-sided otalgia, hyperacusis, postauricular pain, and facial discomfort. Left-sided facial palsy ensues, with associated oral incompetence, facial weakness, and asymmetry progressing to complete flaccid paralysis by the next morning. On physical exam, the resting appearance of the left face demonstrates brow ptosis, a widened palpebral fissure, effacement of the left nasolabial fold, and inferior malposition of the left oral commissure. There is complete absence of brow movement, incomplete eye closure with full effort, and loss of smile, snarl, and lip pucker on the affected side. The remainder of the history and physical exam are unremarkable.
Other presentations
Postauricular pain commonly occurs concurrently or as a prodrome to facial palsy in Bell's palsy.[1] At least one study demonstrated that up to 8% of those diagnosed with Bell's palsy present with additional cranial neuropathies, most commonly of the trigeminal nerve.[11] However, additional cranial neuropathies could indicate another etiology of facial paralysis and further workup may be necessary.
Facial weakness in Bell's palsy may range from a mild palsy to complete flaccid paralysis with absence of volitional and evoked electromyography (EMG) activity. One author has defined four patterns of facial palsy onset in Bell's palsy in order of worsening prognosis: 1) sudden incomplete, without progression; 2) sudden incomplete, with progression, yet remaining incomplete; 3) sudden complete; and 4) sudden incomplete, with rapid progression to complete.[12] Degrees of otalgia, postauricular pain, facial dysesthesias, hypogeusia, and hyperacusis vary.
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