Bells vs stroke

CbrMonster

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Possible stupid question, but I’ve got mixed information on this,

In medic school they taught us that if the patient is able raise both eye brows symmetrically it’s less likely to be a stroke and more indicative of bells

ie: patient has slurred speech facial drop and unable to close one eye completely but is able to raise both eye brows.

reading JEMS and some other quick search links says the opposite
 

DesertMedic66

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Possible stupid question, but I’ve got mixed information on this,

In medic school they taught us that if the patient is able raise both eye brows symmetrically it’s less likely to be a stroke and more indicative of bells

ie: patient has slurred speech facial drop and unable to close one eye completely but is able to raise both eye brows.

reading JEMS and some other quick search links says the opposite
The JEMS and other articles you searched are accurate. Bells typically causes a unilateral facial paralysis which would make the patient unable to furrow their brow and/or close their eye on the effected side.
 

MMiz

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This EMSWorld chart has a good comparison of the two.

This JEMS article has a chart on the typical presentation of both.

Beyond that, I'm not sure I have much to offer. I think largely due to the age of the population I treated, I've never seen Bell's Palsy in the field.
 
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CbrMonster

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The JEMS and other articles you searched are accurate. Bells typically causes a unilateral facial paralysis which would make the patient unable to furrow their brow and/or close their eye on the effected side.
sweet thanks I was assuming they were correct, but always like to double confirm

This EMSWorld chart has a good comparison of the two.

This JEMS article has a chart on the typical presentation of both.

Beyond that, I'm not sure I have much to offer. I think largely due to the age of the population I treated, I've never seen Bell's Palsy in the field.
Those were the two articles I ran across first that contradict what I was taught in school, I assumed they were both right.
 

DesertMedic66

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sweet thanks I was assuming they were correct, but always like to double confirm


Those were the two articles I ran across first that contradict what I was taught in school, I assumed they were both right.
Unfortunately I have found that several things I was “taught” in medic school were not correct.
 
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CbrMonster

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Unfortunately I have found that several things I was “taught” in medic school were not correct.
I learn something new everyday, it’s frustrating though when something is taught wrong. Fortunately it wasn’t my patient or anything of that nature.
 

silver

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This EMSWorld chart has a good comparison of the two.

This JEMS article has a chart on the typical presentation of both.

Beyond that, I'm not sure I have much to offer. I think largely due to the age of the population I treated, I've never seen Bell's Palsy in the field.
The most important section of those articles is the part highlighting that certain rare brainstem strokes mimic Bell's, specifically pontine infarcts as they are infranuclear to the facial motor nucleus and present as "peripheral" lesions. When in doubt err on the side of stroke. They often present much acuter that Bell's.
 

E tank

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Put your clinical findings into context as well...if it looks like BP, smells like BP and quacks like BP in a life-long smoker with a fib and you don't treat it like a stroke, you might be sorry...
 
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CbrMonster

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The most important section of those articles is the part highlighting that certain rare brainstem strokes mimic Bell's, specifically pontine infarcts as they are infranuclear to the facial motor nucleus and present as "peripheral" lesions. When in doubt err on the side of stroke. They often present much acuter that Bell's.
I very much error on the side of caution and unless outside our protocols stroke window activate it. Most strokes I’ve ran into have been very severe except for one which had was a middle aged man that had jarhon aphasia and no other symptoms
 

ffemt8978

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I learn something new everyday, it’s frustrating though when something is taught wrong. Fortunately it wasn’t my patient or anything of that nature.
The day you stop learning is the day you need to get out of this field because you are a danger to your patients.
 

Peak

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The finding of an acute focal neurological deficit should be treated as an emergency until adequately evaluated and proven otherwise.

Bell’s palsy is the result of a viral infection of the facial nerve. It is not unreasonable for a patient to have bells or another non-stroke related facial weakness on only a portion of the facial nerve, or along multiple nerves.

Arch Intern Med. 2004;164(21):2383.

BACKGROUND: There is controversy regarding whether, and how frequently, other cranial nerve deficits accompany Bell's palsy. We sought to determine prospectively the presence of signs indicating an associated cranial neuropathy in patients with Bell's palsy.
METHODS: All subjects presenting to an emergency department with Bell's palsy over a 2-year period were evaluated. The study included 51 consecutive patients. One patient with Bell's palsy was not examined by a neurologist at the time of presentation and was excluded. The main outcome measure was presence of other cranial nerve deficits.
RESULTS: We identified 4 patients with additional cranial neuropathies (contralateral trigeminal [n=1], glossopharyngeal [n=2], and hypoglossal [n=1]). We also identified 13 patients with ipsilateral facial sensory loss, suggesting an ipsilateral trigeminal neuropathy; 3 patients with a contralateral facial palsy; and 3 patients with hearing impairment.
CONCLUSION: This prospective study indicates that a small percentage (approximately 8%) of patients with otherwise typical Bell's palsy may harbor additional cranial neuropathies.


Ann Emerg Med. 2005 Jul;46(1):64-6.

We report a case of an isolated facial nerve palsy in a young, otherwise healthy man who was found to have a pontine hemorrhage on computed tomography. Pontine hemorrhage is a rare cause of facial nerve palsy and has been reported in the literature as an isolated neurologic finding in only 1 other instance. This case reminds the emergency physician to remain vigilant for alternative causes of facial nerve palsy other than "idiopathic" Bell's palsy.

J Med Case Rep. 2011;5:287. Epub 2011 Jul 5.

INTRODUCTION: Isolated facial nerve palsy usually manifests as Bell's palsy. Lacunar infarct involving the lower pons is a rare cause of solitary infranuclear facial paralysis. The present unusual case is one in which the patient appeared to have Bell's palsy but turned out to have a pontine infarct.
CASE PRESENTATION: A 47-year-old Asian Indian man with a medical history of hypertension presented to our institution with nausea, vomiting, generalized weakness, facial droop, and slurred speech of 14 hours' duration. His physical examination revealed that he was conscious, lethargic, and had mildly slurred speech. His blood pressure was 216/142 mmHg. His neurologic examination showed that he had loss of left-sided forehead creases, inability to close his left eye, left facial muscle weakness, rightward deviation of the angle of the mouth on smiling, and loss of the left nasolabial fold. Afferent corneal reflexes were present bilaterally. MRI of the head was initially read as negative for acute stroke. Bell's palsy appeared less likely because of the acuity of his presentation, encephalopathy-like imaging, and hypertension. The MRI was re-evaluated with a neurologist's assistance, which revealed a tiny 4 mm infarct involving the left dorsal aspect of the pons. The final diagnosis was isolated facial nerve palsy due to lacunar infarct of dorsal pons and hypertensive encephalopathy.
CONCLUSION: The facial nerve has a predominant motor component which supplies all muscles concerned with unilateral facial expression. Anatomic knowledge is crucial for clinical localization. Bell's palsy accounts for around 72% of facial palsies. Other causes such as tumors and pontine infarcts can also present as facial palsy. Isolated dorsal infarct presenting as isolated facial palsy is very rare. Our case emphasizes that isolated facial palsy should not always be attributed to Bell's palsy. It can be a presentation of a rare dorsal pontine infarct as observed in our patient.


Ann Emerg Med. 2014;63(4):428. Epub 2013 Jul 25.

STUDY OBJECTIVE: We evaluate the incidence of potentially incorrect emergency department (ED) diagnoses of Bell's palsy and identify factors associated with identification of a serious alternative diagnosis on follow-up.
METHODS: We performed a retrospective cohort study from California's Office of Statewide Health Planning and Development for 2005 to 2011. Subjects were adult patients discharged from the ED with a diagnosis of Bell's palsy. Information related to demographics, imaging use, and comorbidities was collected. Our outcome was one of the following diagnoses made within 90 days of the index ED visit: stroke, intracranial hemorrhage, subarachnoid hemorrhage, brain tumor, central nervous system infection, Guillain-Barrésyndrome, Lyme disease, otitis media/mastoiditis, or herpes zoster. We report hazard ratios (HRs) and 95% confidence intervals (CIs) for factors associated with misdiagnosis.
RESULTS: A total of 43,979 patients were discharged with a diagnosis of Bell's palsy. Median age was 45 years. On 90-day follow-up, 356 patients (0.8%) received an alternative diagnosis, and 39.9% were made within 7 days. Factors associated with the receiving alternative diagnosis included increasing age (HR 1.11, 95% CI 1.01 to 1.21, every 10 years), black race (HR 1.68; 95% CI 1.13 to 2.48), diabetes (HR 1.46; 95% CI 1.10 to 1.95), and computed tomography or magnetic resonance imaging use (HR 1.43; 95% CI 1.10 to 1.85). Private insurance was negatively associated with an alternative diagnosis (HR 0.65; 95% CI 0.46 to 0.93). Stroke, herpes zoster, Guillain-Barré, and otitis media accounted for 85.4% of all alternative diagnoses.
CONCLUSION: Emergency providers have a very low rate of misdiagnosing Bell's palsy. The association between imaging use and misdiagnosis is likely confounded by patient acuity. Increasing age and diabetes are modest risk factors for misdiagnosis.
 

Akulahawk

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In the field, if you see unilateral facial weakness, treat it as a stroke. Why? Simple, it very well could be a stroke. Anticipate the worst, let the neuro folks figure out the cause of the facial weakness and if it turns out to be Bell's Palsy, fabulous. However if it turns out to be a stroke, well... if you found some way to convince the patient to refuse care, you're the one that is going to be in a very hot seat. This is something you don't want to "miss." If you're out a long way away from definitive care, if you can manage to get med control or a neuro doc on a video chat, that might be very helpful in determining whether to get going very fast or not in getting the patient to definitive care.
 

DrParasite

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TBH, my EMS supervisor experienced this who on shift... took him to the ER, dx with bells.

Realistically, what is the downside to treating it as a stroke? Meaning other than take to a stroke specialty hospital vs local ER (since we don't do anything special for stable strokes right?), treat it as a stroke, and let the ER make the final dx.

This is one of those cases where I would be totally ok with over-treating, and telling both the patient and family that we over treated the patient, erred on the side of caution, and they are actually fine with no long term consequences. Because our over treatment is just the transport destination, not an actual intervention.
 

Tigger

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I think the potential issue here is having mis-educated providers look at Bell's Palsy patient and say "you're having a stroke" when the patient is telling them that they are not and has a history of Bell's Palsy. There's no reason to coerce a patient into going to the hospital if they are comfortable with a chronic condition and the provider is not.
 

DrParasite

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I think the potential issue here is having mis-educated providers look at Bell's Palsy patient and say "you're having a stroke" when the patient is telling them that they are not and has a history of Bell's Palsy. There's no reason to coerce a patient into going to the hospital if they are comfortable with a chronic condition and the provider is not.
See, now you are adding additional history that wasn't present previously.

If someone has a history of Bell's Palsy, then I will have a much higher index of suspicion that it is not a stroke. I might even have them do the "furrow the brow" test. If the patient says they have experienced it before, this is what it felt like, I'm not going to coerce them into going (same as if they say they have experienced spontaneous pnemos, and this is exactly what it felt like; even if it doesn't present the same way, I'm going to believe the patient).

But guy on the street, no history of bells? I might still do the furrow the brow test, but we are going to treat it as a stroke... and if my old medical director wanted to call me into his office to explain my actions, I'm pretty sure I could defend my actions to his satisfaction
 

Peak

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I think the potential issue here is having mis-educated providers look at Bell's Palsy patient and say "you're having a stroke" when the patient is telling them that they are not and has a history of Bell's Palsy. There's no reason to coerce a patient into going to the hospital if they are comfortable with a chronic condition and the provider is not.
Also keep in mind that it is statistically unlikely to have more than one acute episode of Bell’s palsy, and a history of Bell’s palsy certainly does not exclude the possibility of acute stroke.

If a patient had an acute episode of chest pain one month ago and was diagnosed with costochondritis it wouldn’t exclude the possibility of cardiac disease if the patient had new acute chest pain today.
 

Tigger

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See, now you are adding additional history that wasn't present previously.
I am adding information for the purposes of discussion, you'll be ok.

There are many cases of EMS providers thinking they know more about the patient's medical history than the patient. Just something to think about. I am well aware that this hardly rules out a stroke.
 

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