Dear Doc | Did I have a stroke?

Q Dear Doc, I am very concerned about some care I have been getting. I recently woke up and my face was twisted and looked lean, and I couldn’t smile properly. I thought at first that I slept bad, so I was just watching it, until I notice my mouth started to water and drain from one side. I got scared and thought it was a stroke, so I went to the doctor. All he did was say it wasn’t, gave me some medication, and an appointment to come back. I didn’t have the money to go to a private hospital, but I didn’t feel any worse, so I just went home. I am asking you to please explain what this thing is, and if I’m stuck like this.

A You were very correct in thinking you may have been having a stroke, which is medically known as a cerebrovascular accident, or a CVA, but based on what you described your doctor is right, and you should not be worried.

What you have is what is called Bell’s palsy.

Bell’s palsy is a condition that occurs when the nerve that controls the muscles of the face – the facial nerve – becomes injured or even stops working altogether. This causes the facial muscles to become weak or paralysed. Person’s with Bell’s palsy commonly complain of weakness of the muscles on one side of the face, drooping of the eyelid or mouth on one side, or like you, drooling from one side of the mouth.

Most people with Bell’s palsy recover completely, but a small amount may continue to have some remaining symptoms for life.

You also did the right thing by going to see a doctor immediately. It is advised that if you have any signs or symptoms suggestive of Bell’s palsy, you should see a doctor for treatment as this should be started within two to three days of onset.

Now, as stated before, Bell’s palsy is caused by inflammation of the facial nerve. It is believed that this may be caused by a virus, and it is also believed that this virus is often the herpes simplex virus (HSV), the same virus that causes cold sores and genital herpes.

The inflammation causes swelling of the nerve that controls muscle movement to one side of the face. The nerve, on its way from the brain to the muscles of the face, has to pass through a narrow opening in the skull bone. As the nerve becomes more swollen, it gets pressed on the bone and is pinched, and its protective covering is damaged. This then interferes with the nerve’s ability to control the facial muscles, resulting in weakness or even paralysis of the muscles in one side of the face. The weakness of these muscles is what makes it difficult to smile or close the eye, and makes your face look twisted.

Because Bell’s palsy causes one side of the face to be partly or completely paralysed, affected persons will notice some or all of the following:

- Eyebrow sagging.

- Drooping of the eye and corner of the mouth.

- One eye not closing completely.

- In some cases, you lose the ability to close one eye, which causes drying of the surface of the eye (the cornea).

- Loud noises may cause discomfort in the ear on the affected side.

- Some people lose the sense of taste on the front of the tongue.

These changes will affect the appearance of your face, and these changes are often obvious to others and can cause persons with Bell’s palsy to feel self-conscious and distressed, and to avoid social activities.

The symptoms appear over a period of one to two days, and the majority of patients begin to improve within three weeks after it began. Improvement may continue for three to six months.

DIAGNOSING BELL’S PALSY

Now, I think you may be concerned that the doctor didn’t perform any tests, especially since you believed you were having a stroke, but Bell’s palsy is usually diagnosed based on your symptoms and a physical examination. Blood tests and other tests are not usually needed.

The purpose of the treatment is to help you to get better faster, especially if it is started within the first few days. However, you may not have to be treated for Bell’s palsy if your symptoms are mild.

Most people who are diagnosed with Bell’s palsy early (within two to three days), are treated with steroids (e.g., prednisone) for one week. Steroids helps to reduce the swelling to the nerve and improves your chances of recovering completely. They work best when they are started early.

Antiviral medicines (e.g., valacyclovir, or acyclovir) are sometimes used in conjunction with the steroids, especially when the facial weakness is severe.

You will need to go to your follow-up visit with your doctor after you start treatment, even though you were not very pleased. At this visit, he will examine you to ensure the treatment is working and that your symptoms are improving. You can use that opportunity to discuss any questions or problems you may have at that time.

People with less severe symptoms tend to recover more completely. If your symptoms begin to improve within the first 21 days, the chances of full recovery, with little or no remaining weakness in the muscles of the face, are good. However, a small number of people are left with moderate to severe muscle weakness that is permanent.

If the damage to the nerve is severe, it may heal in a disorganised fashion. When this happens, your ability to control separate facial movements may be lost. For example, the following may be noticed:

- When you blink your mouth may twitch.

- Smiling may cause your eye to close.

- When you salivate (e.g., before eating), tears may flow from one eye.

The chances of Bell’s palsy happening a second or third time is uncommon, but not impossible.