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Okay, so that came out creepier than I thought. I told our producer, hey, can you give me, like, a gonging bell or something? He's like, yeah, sure. That sounds terrible. The tolling bell. My goodness. Well, what the heck does a tolling bell have to do with what we're talking about? Well, peripherally, nothing. But loosely, something. God, listen to that. It's horrifying. Oh, my gosh. Y' all remember for who the bell tolls. For whom the bell tolls. Ask not for whom the bell tolls, it tolls for thee. Everybody thinks that's Hemingway. It's not. Hemingway came way later. That was an original poem by John Doane. Actually, way before Hemingway. That's where we also get no man is an island. It's a really nice little piece of prose that ended up becoming more like poetry about, no man is in isolation. We're all intimately tied together. So when somebody dies, you know, affects all of humanity. That's why it says, for whom the bell, it tolls. For the. My goodness. What does this have to do with gynecology or obstetrics? Well, I guess nothing, except that we're talking about Bell's palsy. Oh, there it is. Wow. That was probably one of the worst segues that we've had. Or the best dad joke. I don't know one way or the other. Bell's palsy tolling bell. Huh? Huh? Oh, my goodness. Listen, you don't listen to the show for the comedy. You listen. You listen because of the data, I don't know, maybe some of her stupid comments. But anyway, we are talking about Bell's palsy. Yeah, it's a big deal, guys. And something just came out in the summer of this year, summer of 2025, that called attention to the real impact, the negative impact that this can have both functionally and psychosocially for those affected. And as I've said before, we get ideas for the show either for things hot in press, which in this case, there is something from July 2025 regarding Bell's palsy. We're going to talk about that and we also get ideas from questions that come in or from real world scenarios. Well, just today in clinic, we had a patient who was well into her third trimester who came in for her regularly scheduled appointment with new onset left sided facial droop. Yeah, super concerning. Concerning to us, concerning to the patient. And she did the right thing. She didn't wait. She came right in. And a complete history, of course, a complete physical was done. And the working diagnosis at the end of all was Bell's palsy. Now here's the catch. Her blood pressure was right on the cusp of that 140 over 90 pregnancy abnormal, cut off. All right, so it's like 138 over 89, which totally also goes with this situation. We're going to explain that in this episode. Now, this event, which of course can be super stressful for the patient, super stressful for us, because we don't want to go. If you're pregnant, it's just Bell's palsy, you're going to be fine. Which, which can be true, but we have to be able to discern when it's bells versus something else that potentially is life threatening. Bells. Although it does have this functional and psychosocial impact and negative impairment, it can be a benign issue. However, we don't want to miss something that can mimic a Bell's palsy. Which is what? Anyone? Anyone? A stroke, of course. So we have to be able to, to distinguish and delineate when they're having a str and when it looks like Bell's palsy. And we're going to talk about that. That's where we're going in this episode. This just happened to us yesterday in our clinic and I got called. I got a call from the resident. Hey, this looks like bells. I'm like, hold on, how do you know it's bells? Which I'm not disagreeing with you, but how do we make sure that it's not something else like a stroke? And we're going to cover what we discussed in this episode. So I think I've set it up enough. Let's let our tolling bell. Oh, gosh, that's depressing. Is it? Ask not for who the bell tolls, it tolls for thee. Now that is also a book by Hemingway, by the way, but has nothing to do with it. It's loosely tied to this. But the original for who the Bell Tolls was John Doane way before Hemingway. All right, let's get out of that. When we Come back. We're going to talk about the ins and outs of Bell's pa. Tired of all the spin in women's health education? Yeah, so are we. This is Dr. Chapa's OB GYN, no Spin podcast.
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See, Michael, how hard is it just to find a little, cutesy little bell sound that's not like the death march. All right, let's get out of that nonsense. Bell's palsy. Bell's palsy is been around for a long, long time from when Sir Charles Bell first described the condition and first identified actually the facial nerve back in the mid 19th century. So Bell's palsy is named after this surgeon. He was Scottish and he was an anatomist. And he found, oh, look, there's this little nerve that kind of exits through the side of the face. There's little foramen and kind of innervates a lot of the distribution to the face. So Sir Charles Bell, Scottish surgeon and anatomist, found the actual path and the location of the facial nerves. Right? That's where we get the condition. Bell's Palsy. Fascinating, fascinating, fascinating. And just put things in proper context. Remember, we're doing this from a women's health perspective. So I don't know much about Bell's palsy in men, except it pretty much follows the same pathophysiology and treatment. But just to be clear, as a women's health podcast, we're doing this as it relates to women's health and specifically pregnancy, because pregnancy is a big deal here. Because the, the relative risk of this happening is much greater in pregnancy by anywhere from a relative risk of 2 up to a relative risk of 4 based on who you risk over the non pregnant female population or men. Okay, so much more common, first of all in women, period, and then much more common in women who are pregnant. If you take a look at an. At an overall rate, it seems to be about 17.4 per 100,000. 17.4 in 100,000 in the non pregnant population. But listen to this. In pregnancy, guys, in pregnancy, that 17 goes up to 45 cases per 100,000. So I get that this is not like super, super common, but it's not rare either. I mean, it's out there. I mean, it happened to us and it's not the first time. We've had many patients with Bell palsy during pregnancy. I'm going to get into the trimester specific incidence of this because. Spoiler alert, as we mentioned in the intro, much more common. Much more common. Almost universally common in the third trimester, although it doesn't exclude. As long as it cannot happen in the first trimester or the second, it's just much more likely to happen in the third. Okay, so you take a background incidence of about 17.4 or 7 days, let's call it 17 per 100,000. That goes up to 45 cases per 100,000. Hundred thousand during pregnancy. And of course, this is per annum. This is annually. Now, I mentioned in the intro that there was something in July of 2024 that had relevance to this. And there was indeed. This was out of the Journal of Plastic Reconstructive and Aesthetic Surgery that found that, yeah, hey, Bell's palsy, don't minimize it. Basically, don't say, I'll go away, it'll be fine. No, you actually have to be. You have to be aggressive in treatment and treat it early. We get into that in this episode and don't minimize this as just a minor issue. It'll likely go away. Sometimes it can take a long time to go away. And those who are pregnant in pregnant women, guys, the chance of this thing lasting longer is significantly increased. Okay, so it tends to be a little bit worse in terms of the palsy in pregnancy compared to men or non pregnant women. Okay? Now, the good news is, and when we get into this a little bit, I'm kind of going ahead of myself. It doesn't seem to affect. There's no fetal implications here. This is just. It seems to be worse in a pregnant woman compared to a non pregnant woman. Okay? But in July of 2025, in the Journal of Plastic Reconstructive and Aesthetic surgery, July of 2025, this year, just this summer, out of this plastic surgery journal, not because this requires plastic surgeries, it's because they deal with the face they concluded with, with this review, like, yeah, hey, this is real functional limitations. Then it has psychosocial implications and there's peripheral damage that can happen, like the eye. We're going to talk about that because you got to take care of the eye. In Bell's palsy, while it's important to not bite your tongue, not important not to bite your cheek because you can't feel anything on that side of the face, it's super important to discuss with them eye health on the affected side. Because eye desiccation, especially during sleep, is real. I mean, it's stuff that we take for granted. Right? It can severely affect the eye. So you need specific eye care. We'll talk about that in just a little bit. And then in pregnancy, Bell's palsy can bring with it a friend for the ride. And we'll talk about that in a minute. Okay? Now, oddly enough, July of last year, okay, so July of 2024. July of 2024. This July 2025 was the publication of the Plastic Surgery Journal. But last year in July, ACOG had a clinical expert series on neurological emergencies in pregnancy. Do you remember that? Actually, one of our partners spoke on that. Kind of summarize the high points at that one of the conferences that we had here locally. And it was good. It was very, very good. And of course talked about stroke, talked about seizure, talked about central venous thrombosis, all of the things that are real emergencies. But just FYI, in July of 2024, in that ACOG Clinical Expert Series, you know, Bell's palsy is not in there. And I get that it's not an emergency. At the same time, it can't be ignored. So if a patient calls the office, calls you or your clinic and says, hey, I'm preg, I'm in the third trimester, my face, my face is going numb. I mean, one side of my face is Drooping. Do not. Now you can do what you want to do. I'm just letting you know it's best practice. Do not go. Look, you'll be fine. Relax. We'll see you in two weeks. Let us know how it goes. No, you need to bring them in. You need to bring them in to make sure that you're not missing something else. They need a good neurological exam. Not by a neurologist. We all can do that. You know, basic neuro exam, make sure that there's no cognition issues, check their blood pressure, make sure that. That. That it's not just de facto going primary to Bells. You've got to rule everything else out and then go. Now, I can confidently say it's Bell's palsy, because there is no one diagnostic test. Diagnostic test for Bells. You have to exclude other bad things for it. Okay, So I just thought that was interesting that In July of 2024, in that ACOG Clinical Expert Series, they did not include Bell's palsy. But I understand why. Not technically an emergency. Although facial droop is an emergency because that stroke. All right, so you. It is and it isn't. Bells isn't. Facial droop is. And that's how they got into that in terms of the stroke workup. Okay, okay, so back to Bell's palsy. It's an issue of which nerve. Remember, you know, facial nerve. Yeah, that's easy. But which cranial nerve is it? Ooh, you got to go back to. You got to go back to gross anatomy. I asked that to one of my medical students who's still in medical school, who just did gross anatomy not long ago. I said, which. Which is the. Which. Which cranial nerve is the facial nerve? Like. Well, it's the facial nerve. Well, thank you for that circular answer. No, which facial. Which cranial nerve is the facial nerve? The answer I got was, well, the facial nerve. Lord have mercy. I told them they needed a refund. The Cranial Nerve 7. Cranial Nerve 7 is the facial nerve. Come on, guys. Cranial Nerve 7, appropriately called the facial nerve, right? So from Sir Charles Bell, from where we, of course, landed, to this phenomenon called Bell's palsy. Now, it's primarily a motor nerve, right? That supplies motor function, but it also has some parasympathetic sensory fibers that go, like, to the salivary gland, the lacrimal gland, and that's a big deal because that helps keep things moist in the mucous membranes, both of the oral cavity, the nasal cavity, and also in good lubrication to the eye because it can desiccate if the eyelid doesn't close. Right. That's part of the motor function. So the motor function innervates a lot of the muscles of the face, including those of facial expression, but it also carries some parasympathetic fibers for salivation and for the lacrimal glands, specifically for, and mainly for the oral and the nasal cavities. But because that muscular function to the eyelid is affected, it can affect eye dryness as well, with some potentially some peripheral effect on lacrimation of the eye. Okay, okay, fine. So that being said, what's the cause of this now? Plenty of great explanations and we all get this. We all say the same thing. Oh, it's either viral or it's a little bit of inflammation from pregnancy from fluid retention as a nerve exits through its foramen. Yeah, all that's great. All that is sounds super plausible. Truth is, nobody's actually proven that's the case. Although those have absolute biological plausibility and we know that they do happen. Okay, so is it just inflammation or compression of the facial nerve as it exits its little frame in at the lateral skull? Is it, is it a viral paraviral phenomenon mainly due to herpes simplex virus for which antiviral medication can be given? We'll talk about that in a minute. Is it a part of immunosuppression like with pregnancy? And the answer is yes. All of those, those are all very good working explanations. The truth is those are, those are good theories. And then we've kind of stuck with that, but nobody really has a true one answer. We know this is a cause of bell. We don't know that. But those what I've told you, those three things are basically the working hypothesis of causation, inflammation, compression of the nerve as it exits the sheath and through the facial muscles. Number two is possibly some paraviral issue. And then number three, it could be an effect of immune modulation of pregnancy as it affects nerve conduction and transmission. All of those are likely theories, but none of those are proven. Okay, as we mentioned a little while ago, pregnant patients with bells tend to have worse long term facial outcomes compared to non pregnant women or compared to men. It can hang around a little bit longer. The facial weakness seems to be a little bit more pronounced. They have lower rates of recovery and higher rates of persistent facial weakness than when not pregnant. This is why you don't minimize it. That's why you sympathize with them. And you go, we're going to get you on some Medication. We don't really know how effective it is, but we got to do something. And the consensus opinion is to do just that. Do something. Some people just use corticosteroids by themselves for about a 10 day taper. Others do combination therapy of steroids and antiviral. That's what we do because it doesn't hurt and it can only possibly help. Although the data is great. Okay. Some studies have shown that adding antiviral to steroids doesn't add much benefit. Others have said, no, it works much better. So we don't know I'm in the favor of antiviral medications. Definitely not going to hurt. Valacyclovir is not going to hurt and it could potentially help. I do both. The catch is that the initiation of treatment is directly related to the quickness of resolution. So if somebody comes in a week after it started, you can give them that medication. It's probably not going to work because with things with the nervous system, of course, you got to get in quickly, identify and remedy. Identify and remedy. So most consensus opinions based on the literature that we've read, of course our references are in our show notes. You want to get ahead of this and start treatment within 48, ideally within 72 hours. Okay. All right, podcast family, I tell you what, why don't we take a little a quick break here. When we come back, I want to talk about how do we differentiate Bell's palsy and isolated unilateral facial droop from the more complicated and potentially life threatening issue of a CVA of a stroke. We're going to do that when we come back. This is, excuse me, a damn fine cup of coffee podcast family. Unique to the Chop up podcast community, the Strong Coffee Company offers 20 discount to whatever you purchase online through the link in our show notes. That's right, it's unique to our podcast community. The Strong Coffee Company is not your routine cup of coffee. It is coffee 2.0 and it's coffee that works as hard as we do. There are latte options, there's whole bean options as well. And this comes with collagen as well as L theanine and adaptogens to boost overall performance and mental acuity without the caffeine crash. There's actually published peer reviewed evidence from this from July of 2024 in Acta Clinical Nutrition. So this combines my two favorite things, my love of coffee and my love of data in my morning cup of coffee. So the Strong Coffee Co. Offers 20% discount to through the link only in our show notes. So As a thank you to being part of our podcast community, the Strong Coffee Company has partnered with us for a 20% discount on anything purchased online.
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All right, podcast family, so we don't want to miss a stroke here and just assume it's Bells. So we gotta look at the history, gotta take the history very well, see how this thing presented and also look at the face very well because in general, Bell's palsy looks different than a stroke. Bell's palsy typically involves paralysis or weakness of the entire half of the face, and that includes the forehead. So they can't raise their eyebrow or wrinkle the forehead on the affected side. Guys, that's a big win and easy to do at bedside. All right. Bells typically involves the whole half of the face, however, with a stroke, because that's upper motor neuron lesion that typically spares. Now, I guess I know, I know that there's exceptions to things, but in general, stroke tends to spare, avoid the upper third of the face. So this allows the individual who's having a stroke to still raise their eyebrow and wrinkle their forehead on the affected side. So that's a big caveat. There is one is just look at them and say, hey, wrinkle your forehead, raise your eyebrow. Because Bells is going to. It's a bum carte blanc. Whole side of the face goes cut out because of the innervation of the facial nerve, as opposed to an upper motor neuron that spares the top part of the face. In general, also, these things tend to appear differently. A stroke obviously is. Is very sudden onset. Boom. It just knocks them out. Maybe accompanied by other neurological issues like a bad headache or weakness in the arm or leg. They can have confusion, they can have difficulty speaking, they can have difficulty understanding loss of balance. None of that goes with Bel. Bells is just, hey, my face, my face is going numb. Okay, that's very isolated. Once again, a full history, super important. And ask them to do hand grasp, lift, leg raises, foot raises. You got to take a look to make sure that sensation is okay. Nothing else is going on in the peripheral locations. Bell's palsy, unlike the Stroke that happens immediately, starts slow. Okay. First, like, something's kind of weird with my face, kind of tingly. It's odd, you know, maybe a little numb. And then it progresses over 48 hours. So if somebody says, I just woke up this way, you got to ask them, are you sure you just woke up this way? Because I'm concerned. Or. Or has this been happening over, like, the last day? How'd you feel yesterday? Almost universally with Bells, they're going to say, yeah, yesterday my face felt kind of weird, felt kind of numb. Yeah, because it progresses over 48 hours. Okay, so stroke, sudden onset stroke, other things going on. Stroke tends to spare the upper forehead. Now, if there's any concern, any concern, be quick to get an mri. Okay? But for Bell's palsy, that's pretty classic symptomatology findings during the third trimester pregnancy. You don't have to get an MRI for that. It's all right. Just start them on treatment and ideally again, within 48 to 72 hours. But those are some key, very simple at the bedside things to keep in mind to help distinguish stroke, sudden onset, lower third of the face. So her lower half of the face and other neurological issues. Bells a little bit more insidious, and then, boom, your face goes out, usually the entire side of the face and nothing else going on. But again, if there's any concern, get an mri. Now, here's another big clinical pearl. As I mentioned a little while ago, I think it was in the intro. Bells in pregnancy tends to bring a friend for the ride. Okay? Now, it's not a direct causation one way or the other, but it's a good association. And I can get into this because I've had the discussion on association versus causation more than I've cared to in the last three to four days on another issue. But there is a very strong association between Bell's palsy and hypertensive disorders of pregnancy. Remember I said our patient was kind of threatening to have that 140 over 90 cutoff because she's likely going to get preeclampsia or gestational hypertension. We know that there is this tie bilaterally. So hypertensive disorders of pregnancy. Bam. More likely to get bells. And then those who first present with bells, watch them because within the next week or so, they may have high blood pressure. Documented. That wasn't there before. It's not 100. But there is a very well known and very well documented association between Bell's palsy and hypertensive disorders in Pregnancy. So tell them this is benign, but this could be a sign that blood pressure is going to go wacky or is already wacky. And we gotta, you know, pay attention to that. That as a little side note, as we talked about care for Bell's palsy a little while ago, and this is something we tend to forget. We talk about, you know, oh, no adverse perinatal issues. It tends to be a little bit worse in pregnancy than non pregnancy. You know, you got to, you take your medicine quickly. We'll talk about medication in a minute. But we forget this issue about eye care. So at night, guys with Bell's palsy, they need to go to their favorite neighborhood pharmacy and get a little eye patch to cover that eye at night. And before they go to bed, they need to put eye drops. And if they wake up at night to go pee, they got to put, put another eye drop because eye desiccation is a big deal because her eyelid doesn't have the, the strength to close correctly. And there's been a lot of, of ocular desiccation and corneal abrasions because of Bell's Palsy. If they go outside, they got to wear a sunglass or a patch because the eye doesn't close well. And that direct sunlight can actually damage the eye. My point is they got to watch how they chew because they can, you know, bite their tongue or their cheeks. I got to be careful with that. And the eye. Eye care is big. Eye care is big with Bell's palsy. Oh, on a side note, which has nothing to do with what we're talking about, but kind of so related to the eye in our group, which I'm very proud of. Our group, our group is multidisciplinary. We've got obgyn. Hello. We've got pediatrics, cardiology, family medicine, sports medicine, behavioral health. What am I missing? Is that it? I feel like I'm missing something. Oh. Anyway, I guess that's it. Oh, I'm sorry. Internal medicine. That's our group. Group. But one of our intro medicine physicians is also, by the way, an astronaut. Yeah, like legit astronaut. Like, has been up to the space station because she's in aerospace medicine. And she said one of her, the things that she was working on in, in terms of her research was how space affects the eyeball. Apparently there's. It affects the optic nerve if you're up there too long and the pressure's in the eye. What? So who would have known? Anyway, yeah. So one of our partners is an astronaut. How cool. Is that that? Which means I can never win. Like, you know, I'm saying, hey, I went in, I saved a baby from this abruption. You know, it was great. I've been to the space station. Like, I can never win, right? Oh, my gosh. We had this great shoulder show. I took it out in 15 seconds. Post your arm removal. We saved that baby. I was fine. Everyone's good. I've been to the space station. It's like, you can never win. That's the card you can never outplay. But thankfully, she's super humble. She's actually brilliant. Brilliant. Yeah. So one of my partners is an astronaut. How you like that? That okay? Nothing to do with Bell's palsy. Michael, why did you. Why do you let me do that? Hold on. Oh, here. Here we go. Okay. Bell's palsy treatment. So in brief, very easy. Start quick, start quick and do an exam. Prednisone for about 50-60mg a daily for about 5 days, then followed by a 5 day taper is traditional. Some do a Medrol dose pack, which is fine, but that's only about seven days. Some say it's fine because you hit it real hard at first and then taper down. Point is, do some kind of of steroid and prednisone or a Medrol dose pack. Methylprednisolone seems to be just fine. The issue is, do you add Valacy cyclophyr to that or not? And the data is perfectly gray. Again, there is data that the combined treatment seems to reduce persistent deficits. While just to be clear, there's other data that say that's not the case. I feel that valcyclovir is not going to hurt. It's not an antibiotic, it's totally fine to take. And even though the data is gray on combined therapy, there is some evidence that it's helpful. And this is something we don't want to mess up because again, functional and socios. Social psychosocial impacts of. This is real, as The July of 2025 publication stated in the Journal of Plastic Reconstructive Anesthetic Surgery. Okay, so I think we've kind of covered our deal here on Bell's palsy. Somebody calls the office, does it have facial droop? Bring them in. I mean, that's a hard stop. You got to make room in the clinic, you got to see them. And ideally start treatment within 72 hours. If Bell's palsy is indeed the flavor that the patient is putting out. Okay. Otherwise you got to get a head ct, make sure nothing else is missing. But if it's run of the mill Bell's palsy, the need for additional imaging or tests is just not necessary. If you document well that this fits the classic presentation of Bell's palsy compression of the facial nerve and or inflammation and or nerve modulation from pregnancy or a post viral syndrome, those are the working theories and we're going to give her both steroid and an antiviral and then follow closely for the development of hypertensive disorders of pregnancy. That's the management of Bell's palsy in pregnancy. Podcast Family as always, we're thankful for you. We're glad you're part of our podcast community. Now that we've done all that, let's take it home. Podcast Family, we really are thankful for you. We hope you enjoyed this episode. We'll see you next time on Clinical Pearls. SA Sat.