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Acute facial paralysis over the last days.
A history of a facial twitch or spasm that precedes facial weakness suggests nerve irritation from tumor and should prompt imaging.
Onset of facial weakness in Bell's palsy occurs over several hours, up to 72 hours. Symptoms may worsen for days, up to three weeks, then stabilize to improve. When symptoms occur suddenly or fail to improve at least partially by four months, alternative diagnoses should be considered.
central causes of facial weakness due to unilateral upper motor neuron conditions such as stroke or tumor produce facial weakness restricted to the lower portion of the face because nerve branches from the facial nucleus to the eyelid and forehead receive fibers from bilateral corticobulbar fibers.
Laboratory testing for Lyme disease is warranted for patients in areas where the disease is endemic.
Features that are atypical for Bell's palsy include:
•Bilateral acute facial weakness
•Additional cranial neuropathies or other neurologic signs
•Systemic signs (eg, rash, swelling, cervical adenopathy)
•Sudden onset of symptoms at maximal severity (ie, no progression)
•Insidious onset of symptoms (eg, over weeks to months)
•Continued worsening of symptoms beyond three weeks
•No improvement in symptoms within four months of onset
MRI = 1st choice of imaging
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