Facial paralysis is a common medical complaint—one that has fascinated ancient and contemporary physicians alike.1 An idiopathic facial nerve paresis involving the lower motor neuron was described in 1821 by Sir Charles Bell. This entity became known as a Bell’s palsy, the hallmark of which was weakness or complete paralysis of the muscles of one side of the face, with no sparing of the muscles of the forehead. However, not all facial paralysis is due to Bell’s palsy.
We present a case of a patient with a Bell’s palsy mimic to facilitate and guide the differential diagnosis and distinguish conditions from the classical presentation that Bell first described to the more concerning symptoms that may not be immediately obvious. Our case further underscores the importance of performing a thorough assessment to determine the presence of other neurological findings.
Case
A 61-year-old woman presented to the ED for evaluation of right facial droop and sensation of “room spinning.” The patient stated both symptoms began approximately 36 hours prior to presentation, upon awakening. She further noted that the right side of her face felt “funny” and numb.
The patient denied any headache, neck or chest pain, extremity numbness, or weakness, but stated that she felt like she was going to fall toward her right side whenever she attempted to walk. The patient’s medical history was significant for hypertension, for which she was taking losartan. Her surgical history was notable for a left oophorectomy secondary to an ovarian cyst. Regarding the social history, the patient admitted to smoking 90 packs of cigarettes per year, but denied alcohol or illicit drug use.
Upon arrival at the ED, the patient’s vital signs were: blood pressure, 164/86 mm Hg: pulse, 89 beats/min; respiratory rate, 18 breaths/min; and temperature, 98.6°F. Oxygen saturation was 98% on room air.
Physical examination revealed the patient had a right facial droop consistent with right facial palsy. She was unable to wrinkle her right forehead or fully close her right eye. There were no field cuts on confrontation. The patient’s speech was noticeable for a mild dysarthria. The motor examination revealed mild weakness of the left upper extremity and impaired right facial sensation. There were no rashes noted on the face, head, or ears. The patient had slightly impaired hearing in the right ear, which was new in onset. The remainder of the physical examination was unremarkable.
Although the patient exhibited the classic signs of Bell’s palsy, including complete paralysis of the muscles of one side of the face, inability to wrinkle the muscle of the right forehead, and inability to fully close the right eye, she also had concerning symptoms of vertigo, dysarthria, and contralateral upper extremity weakness.
A computed tomography (CT) scan of the head was ordered, which revealed a large mass lesion centered in the right petrous apex, with an associated large component extending medially into the right cerebellopontine angle (CPA) that caused a mass effect on the adjacent brainstem (Figures 1a and 1b).
Figure 1.
Upon these findings, the patient was transferred to another facility for neurosurgical evaluation. Magnetic resonance imaging (MRI) studies performed at the receiving hospital demonstrated a large expansile heterogeneous mass lesion centered in the right petrous apex with an associated large, probable hemorrhagic soft-tissue component extending medially into the right CPA, causing a mass effect on the adjacent brainstem and mild obstructive hydrocephalus (Figures 2a and 2b).
Figure 2.
The patient was given dexamethasone 10 mg intravenously and taken to the operating room for a right suboccipital craniotomy with subtotal tumor removal. Intraoperative high-voltage stimulation of the fifth to eighth cranial nerves showed no response, indicating significant impairment.
While there were no intraoperative complications, the patient had significant postoperative dysphagia and resultant aspiration. A tracheostomy and percutaneous endoscopic gastrostomy tube were subsequently placed. Results of a biopsy taken during surgery identified an atypical meningioma. The patient remained in the hospital for 4 weeks, after which she was discharged to a long-term care (LTC) and rehabilitation facility.
Figure 3.
A repeat CT scan taken 2 months after surgery demonstrated absence of the previously identified large mass (Figure 1b). Three months after discharge from the LTC-rehabilitation facility, MRI of the brain showed continued interval improvement of the previously noted mass centered in the right petrous apex (Figures 3a and 3b).