Herpes Simplex infection (HSV)

is one of the most prevalent STDs, most infections are subclinical and usually self-limited in immunocompetent patients. The majority of anogenital infections are caused by HSV type 2 and, to a lesser degree, HSV type 1. There has been an increase in the number of cases of anogenital infection by HSV-1 as the practice of oral sex has become more widespread.


The HSV infection is characterized by severe anorectal pain. Tenesmus, discharge, and hematochezia are also reported with anorectal involvement. Additional systemic symptoms include fever, malaise, and myalgias. The classic perianal vesicles, pustules, and ulcers can be seen on physical examination.

The virus establishes lifelong latency in the sacral ganglions after the primary infection. Reactivation causes recurrent symptoms with varying intervals depending on physiological and environmental factors. Special attention must be given to immunocompromised patients who are at risk of a disseminated infection. Herpetic proctitis is the most common cause of nongonococcal proctitis in Men having Sex with Men (MSM).

Serotyping can be used to confirm the diagnosis. Detection of HSV-specific IgG has a sensitivity of up to 100% and specificity of 96%. Immunoglobulin G antibodies are negative at the onset of herpes disease and become detectable 2 to 12 weeks after the onset of symptoms and persist indefinitely.

Serology testing has the advantages of being more readily available, efficient (samples are easier to obtain), easily transported  and processed, and allows for differentiation between genital herpes caused by HSV types 1 or 2.

Antiviral medications including acyclovir, valacyclovir, and famciclovir are used for treatment of Herpes Simplex virus lesions. They can reduce the symptoms of the disease. They do not eradicate the virus. They should be administered as soon as possible and at a higher dose during the first episode of the disease to prevent a prolonged, severe, or complicated illness. Thereafter, antiviral therapy can be given episodically for recurrent episodes to shorten the signs and symptoms, or as suppressive therapy to decrease the frequency of recurrences by 70 to 80%. Suppressive therapy also has the advantage of decreasing the risk of HSV-2 transmission to new sexual partners.


Bell's Palsy

Bell’s Palsy is the weakness or paralysis of the facial muscles on one side of your face. If you suffer from it, it may be more difficult to smile, blink, taste, cry, and use other types of facial muscles.

The facial nerve that runs from your brain and through a narrow corridor of bone in your skull. When this nerve becomes inflamed, it may start to grow or move within this shell or facial canal and become pinched by the bone. Once pinched or damaged, the nerve is no longer is able to transmit messages to your facial muscles or send messages back to the brain, and this is the primary cause of Bell’s Palsy.

Certain viral infections have been linked to Bell’s Palsy, and it’s believe that these viruses provoke immune responses and inflammation in your nerve which cause the pinching or compressing.

Signs and symptoms of Bell palsy

Signs and symptoms of Bell palsy include the following:

  • Acute onset of unilateral upper and lower facial paralysis (over a 48-hr period)

  • Posterior auricular pain

  • Decreased tearing

  • Hyperacusis

  • Taste disturbances

  • Otalgia

  • Weakness of the facial muscles

  • Poor eyelid closure

  • Aching of the ear or mastoid

  • Tingling or numbness of the cheek/mouth

  • Epiphora

  • Ocular pain

  • Blurred vision

  • Flattening of forehead and nasolabial fold on the side affected by palsy

  • When patient raises eyebrows, palsy-affected side of forehead remains flat

  • When patient smiles, face becomes distorted and lateralizes to side opposite the palsy




The grading system developed by House and Brackmann categorizes Bell palsy on a scale of I to VI,[1, 2, 3] as follows:

Grade I: normal facial function

Grade II: mild dysfunction

Grade III: moderate dysfunction

Grade IV: moderately severe dysfunction

Grade V: severe dysfunction

Grade VI: total paralysis

There are some viruses that have already been studied and linked as potential Bells Palsy causes. These viruses include:

  • Genital herpes and cold sores (HSV most common)
  • Shingles and chicken pox
  • Cytomegalovirus
  • Mononucleosis
  • Adenovirus and other respiratory viruses
  • Rubella
  • Mumps
  • Influenza
  • Coxsackievirus, (Hand-foot-and-mouth disease)

Other Bells Palsy Causes

These causes include trauma to the face and head, bone fractures in the ear and face, injuries to the brain stem, and surgical wounds in the face. If any of these types of events or injuries damage or put pressure on the facial nerve like CSOM.

Grading of Bell's Palsy

House-Brackmann facial paralysis scale2






Mild dysfunction (slight weakness, normal symmetry at rest)


Moderate dysfunction (obvious but not disfiguring weakness with synkinesis, normal symmetry at rest) Complete eye closure w/ maximal effort, good forehead movement


Moderately severe dysfunction (obvious and disfiguring asymmetry, significant synkinesis) Incomplete eye closure, moderate forehead movement


Severe dysfunction (barely perceptible motion)


Total paralysis (no movement)



Management of Bell Palsy

Goals of treatment: (1) improve facial nerve (seventh cranial nerve) function; (2) reduce neuronal damage; (3) prevent complications from corneal exposure

Treatment includes the following:

  • Corticosteroid therapy (prednisone)

  • Antiviral agents (acyclovir)

  • Eye care: Topical ocular lubrication is usually sufficient to prevent corneal drying, abrasion, and ulcers

Surgical options

Surgical treatment options include the following:

  • Facial nerve decompression

  • Subocularis oculi fat lift

  • Implantable devices (eg, gold weights) placed into the eyelid

  • Tarsorrhaphy

  • Transposition of the temporalis muscle

  • Facial nerve grafting

  • Direct brow lift



  1. Murphy M, Chedister GR, George V. Non-HPV Perianal and Anorectal Sexually Transmitted Viral Infections. Clin Colon Rectal Surg. 2019 Sep;32(5):340-346. doi: 10.1055/s-0039-1687829. Epub 2019 Sep 6. PMID: 31507343; PMCID: PMC6731110.
  2. House JW, Brackmann DE. Facial nerve grading system. Otolaryngol Head Neck Surg. Apr 1985;93(2):146-7


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