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Differential diagnosis

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

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  • Bell's palsy remains a diagnosis of exclusion and must be distinguished from other causes of facial palsy - see facial palsy for more information
  • the differential diagnosis includes:
    • nuclear (peripheral) causes (1)
      • Lyme disease
        • this is more likely if the facial weakness is bilateral
        • history of tick exposure, and arthralgias
        • look for a rash
      • Otitis media
        • suppurative otitis is excluded by examining the ear
        • there is gradual onset ear pain, fever, and conductive hearing loss
      • Ramsay Hunt syndrome
        • herpes zoster may produce an acute facial weakness but is accompanied by a rash within the auricle - geniculate herpes - or on the palate, pharynx, face, neck or trunk. There may be a pronounced prodrome of pain. 2-23% of people with Bell's palsy actually have Ramsay Hunt syndrome and it should be suspected when pain is significant, especially in those aged over 60. (2)
      • sarcoidosis
        • sarcoidosis affecting the parotid gland is suggested by recurrent facial palsy
        • facial weakness is often bilateral
      • Guillain-Barré syndrome
        • facial weakness is often bilateral
      • HIV infection
        • more likely if the facial weakness is bilateral
        • look for lymphadenopathy
      • tumours
        • cholesteatoma, parotid gland tumours
    • supranuclear (central) causes (1)
      • multiple sclerosis
        • multiple sclerosis should be considered if the palsy is unilateral, in a young adult, is painless, and resolves in 2-3 weeks
      • stroke
      • tumours
        • metastases or primary brain tumours
        • history of cancer
        • look for mental status changes
  • Horner's syndrome and 3rd nerve palsies produce a ptosis

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