Many people are familiar with Bell’s palsy, a relatively common condition marked by temporary paralysis of one side of the face. People are so familiar with this condition that they will often call our office after they develop the telltale one-sided facial droop and say, “I think I have Bell’s palsy.” They are almost blasé about it. I have to admit that I am somewhat the same way.
We’ve seen so many cases of Bell’s palsy over the years that when someone calls and says they think that’s what they may have, we are fairly certain they will be correct.
But it’s extremely important to take a drooping face seriously because it can also be a sign of stroke or even a brain tumor. Even if it is just a Bell’s palsy, it’s important to search for a cause. There was a great early episode of the TV show ER (which debuted my first year of medical school, and was watched and hotly discussed by all the students) where Carter, the medical student (at that time) saw a case of Bell’s. Dr. Green, his attending physician, asked him if he looked in the patient’s ear for the crusting and blisters that would help make the diagnosis of Ramsay Hunt Syndrome, a herpes infection of the ear that can result in a Bell’s palsy. In my area, Lyme disease is a frequent cause of Bell’s palsy, so a case should always prompt testing and consideration of treatment.
So when a patient came in the other day with a right-sided facial droop that had started five days earlier, I was ready to make the Bell’s palsy diagnosis. I performed the usual physical exam trick doctors are taught to distinguish a case of Bell’s from stroke—compare the forehead and the lower portions of the face. In a Bell’s palsy the entire side of the face is affected. The mouth droops, the facial folds between the nose and the mouth (the nasolabial folds) are less distinct than the other side, the eye on the affected side may be unable to close entirely, and the forehead appears less wrinkled or creased than the other side. On the other hand, in a stroke, only the lower portion of the face will be affected. The forehead is usually spared in a stroke, while the lower portions of the face droop.
In this patient, the forehead was spared, meaning that this was more likely to be a stroke. We sent the patient for immediate MRI of the head and the diagnosis of stroke was confirmed. Because the patient had waited so long to come in, it was no longer an emergency. Fortunately, his symptoms were relatively mild. His only other sign of stroke had been slurring some words, but that apparently had improved.
This patient was fairly lucky then. It is extremely important to recognize the signs of stroke, and to get medical help immediately, because there are treatments that can reverse a stroke, but they have to be started within three hours of the first symptoms.
So, the point of the story is to understand the signs of stroke, and in this case, the difference between a stroke and a Bell’s palsy. It just might save your life.