Key Points

• Bell's palsy is an acute unilateral paralysis of the facial nerve and involves the forehead muscles.

• Trigeminal neuralgia is usually a unilateral severe lancinating pain lasting a few seconds, triggered by innocuous stimuli (light touch to face, toothbrushing).

• Trigeminal neuralgia is rarely seen in patients less than 40 years of age.

Many conditions or infections may affect the cranial nerves and cause a peripheral neuropathy. Two common problems encountered by family physicians are idiopathic acute peripheral facial paralysis (Bell's palsy) and trigeminal neuralgia (tic douloureux).

Idiopathic Acute Peripheral Facial Paralysis

Bell's palsy is an acute, unilateral paralysis of the facial nerve of unknown etiology but possibly linked to an antecedent herpes infection (Adour, 1975). Bell's palsy is likely the most common isolated cranial neuropathy (23 per 100,000) seen by family physicians (Hauser, 1971). Symptoms tend to develop over hours to days and may be associated with recent upper respiratory infection. Symptoms include partial or complete paralysis of the ipsilateral facial muscles, forehead involvement, otalgia, phonophobia, and cephalgia. If the forehead muscles are spared, one must consider a central etiology to the symptoms. Bilateral findings of Bell's palsy should prompt consideration of GBS, sarcoidosis, disseminated Lyme disease, or diabetes.

Most patients with Bell's palsy will recover with only supportive therapy within a few days to a few months. This makes aggressive treatment controversial. A recent meta-analysis showed that high-dose corticosteroids (>450 mg total dose) were associated with greater benefit and decreased risk of unsatisfactory recovery, whereas antiviral agents showed no benefit alone but may have additional benefit when used with corticosteroids (de Almeida et al., 2009). A typical corticosteroid regimen may include oral predni-sone, 60 mg/day for 7 days, then tapering by 10 mg/day, with or without valacyclovir, 500 mg orally three times daily for 7 days.

Trigeminal Neuralgia

Trigeminal neuralgia (tic douloureux) usually involves the second and third (maxillary and mandibular) divisions of the trigeminal nerve, causing pain of the innervated structures (lips, gums, teeth). It is almost always unilateral, with the pain sudden, sharp, and severe, lasting a few seconds at a time. This cycle of pain can occur hundreds of times a day. It may be described as lancinating, ice pick like, or an electric shock and characteristically is precipitated by innocuous stimuli such as light touch to the face or toothbrushing. It is rarely seen in patients younger than 40. Pain that is longer in duration, bilateral, or described as more aching or pressure like is usually not related to trigeminal neuralgia and should cause the physician to search for another cause. Other conditions that should be considered include multiple sclerosis, acoustic neurinoma, aneurysm, meningioma, trigeminal neuroma, and early herpes zoster or postherpetic neuralgia. Herpes zoster should be suspected in patients younger than 40 who present with pain following the upper division of the trigeminal nerve (forehead and eye). Neuroimaging with MRI scanning of the brain is recommended to exclude these causes from idiopathic disease.

A common initial pharmacologic treatment for idiopathic trigeminal neuralgia is carbamazepine (Tegretol), up to 800 mg/day, or oxcarbazepine (Trileptal), up to 1200 mg/ day. Usually, these medications are started at relatively low doses (100-200 mg once or twice daily) and increased at 7- to 10-day intervals until adequate symptom control is achieved. Patients should be educated that these medicines will only work when taken on a consistent basis and not as an analgesic medication. Other medications that have been used but are not FDA approved include gabapentin (Neurontin), amitriptyline, and baclofen. Toxicities from these medications, including allergic reactions, bone marrow suppression, and liver toxicity, may develop and thus require close monitoring. Patients with refractory symptoms or who do not tolerate pharmacologic treatment should be considered for neurosurgical evaluation.

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