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Bell’s Palsy:

PRESENTED BY-DR NANDANI KUMARIPG II YEAR

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Motor nucleus of VII CN is antero lateral to VI CN

nucleus

Parasympathetic fibres

Red line motor fibers

Visceral afferent fibres

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Submandibular gland

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Bell’s Palsy Defined

It is an idiopathic paralysis of the facial nerve of sudden onset.

Unilateral lower motor neuron paralysis of sudden onset,not related to any other disease elsewhere in the body.

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Who is Bell ?

Charles Bell known for his studies on the nervous system and

the brain. In the 19th century discovered that lesions of the 7th

cranial nerve causes facial paralysis.

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Facial Nerve

Each nerve controls: Eye blinking and closing Facial expressions

Smiling and frowning Tear glands Saliva glands Muscle of small bone in middle of ear called the stapes Taste sensations

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Cause

Unknown cause Evidence shows that reactivated herpes

simplex virus (HSV) may be involved in some cases.  

Reactivation of the HSV causes inflammation, edema, ischemia, and eventual demyelination of the facial nerve, causing pain and alterations in motor and sensory function.  

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May be caused by a viral infection Viral meningitis Herpes simplex

Headaches Chronic ear infections High blood pressure Diabetes Sarcoidosis Tumors Lyme disease trauma

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Because it's swollen, the nerve gets compressed as it passes through a small hole at the base of the skull, which causes the symptoms of Bell's palsy.

Bell's palsy can affect people of all ages, but it is most common in adults.

People with diabetes and pregnant women are more likely to develop Bell's palsy.

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Examination

Differentiate between upper and lower motor neurone lesion

UML: frontalis is spared allowing normal furrowing of brow and eye blinking

LML: all muscles of facial expression are affected

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Evaluation

Careful history – timing Associated symptoms recurrent

Physical exam CT/MRI Electrophysiology

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S/S Varies from person to person

Comes on suddenly Mild to total paralysis

Weakness, twitching on one of both sides of the face

Facial and eyelid droop Drooling Dryness of eye or mouth Impairment of taste Excessive tearing of eye

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Pain behind the ear may precede the paralysis by a day or two .

Impairement of taste is present to some degree in all cases –rarely beyond second week of paralysis.

Hyperacusis or distortion of sound in ipsilateral ear ---paralysis of stapedius muscle.

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Patient feels stiffness of face pulled to one side.

Ipsilateral restriction of eye closure, difficulty with eating ,fine facial movements.

Disturbance of taste –chorda tympani fibres Hyperacusis—fibers to stapedius

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BELL’S PHENOMENON

Normally on closing the eye ,the eyeball moves upwards and inwards.

This is on the affected side due to ineffective closure of the eyelids.

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Clinically Corner of mouth droops Skin folds effaces Forehead is unfurrowed Eyelids will not close Eye on the paralysed side rolls upward –

BELL’S PHENOMENON Lower lid sags and falls away from conjunctiva Tearing. Saliva may dribble from the corner of the mouth Heaviness or numbeness of the face

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House-Brackmann grading system Grade I - Normal Grade II - Mild dysfunction, slight weakness on close

inspection, normal symmetry at rest Grade III - Moderate dysfunction, obvious but not

disfiguring difference between sides, eye can be completely closed with effort

Grade IV - Moderately severe, normal tone at rest, obvious weakness or asymmetry with movement, incomplete closure of eye

Grade V - Severe dysfunction, only barely perceptible motion, asymmetry at rest

Grade VI - No movement

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Diagnosed

There are no specific lab tests to confirm diagnosis Will exam for upper and lower facial weakness Electromyography

Confirm presence of damage and determine severity MRI and CT

causes of pressure on nerve

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Differential diagnosis

Stroke Herpes zooster virus Lyme disease

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Prognosis

80% patients recover within a few weeks.2-12 weeks.

10%--permanent disfigurement.long term sequelae.

8%--recurrence Best clinical guide to progress is the severity of

the palsy during the first few days after presentation.

Recovery of taste precedes motor function.

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If recovery of taste occurs in first week –good prognostic sign.

Early recovery of motor function in the first 5-7 days— most favourable prognosis.

Recurrence is due to reactivation of virus,pregnancy.

Interval between periods is not predictable.

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Treatment

Controversial Symptomatic

Protection of eye during the sleep -patch Massage of the weakened muscles Lubricating eye drops

Prednisolone 60-80 mg/day in divided doses intial 4-5 days,then taper over next 7-10 days. Decreases the possibility of permanent paralysis From swelling of facial nerve in facial canal. Decreases the severe pain.

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Medical treatment

Acyclovir 400 mg 5 times/day Famciclovir and valacyclovir 500 mg

bid

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Surgical treatment

Facial nerve decompression Indication

Completely paralysis Appropriate time for surgery is 2-3 weeks

after paralysis.

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Electrophysiology

Treatment plan based on 16% of patients who do not fully recover

Several tests used for prognosis Measure amounts of neural degeneration occurred

distal to injury by measuring muscle response to electrical stimulus

Able to differentiate nerve fibers undergoing Wallerian degeneration.

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Temporal bone fractures

Signs bleeding from the external canal hemotympanum step-deformity of the osseous canal conductive hearing loss (longitudinal fracture) sensorineural hearing loss (transverse fracture) CSF otorrhea facial nerve involvement (20% of longitudinal

fractures and 50% of transverse fractures)

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Longitudinal VS Transverse

Type of injury

Longitudinal

Transverse

Incidence 70-90% 10-20%

Site of injury

Temporal , Parietal area

Occipital , Frontal area

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Sequelae

Long delay in the onset of recovery—3months Regeneration of nerve –2 years Incomplete

Crocodile tears Facial spasms

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That’s interesting… Famous people that have had Bell’s palsy

Roseanne Barr, American actress and comedian Stevie Benton, Bassist for Texas rock band, Drowning Pool Pierce Brosnan, Irish actor and producer George Clooney, American actor, director, producer and

screenwriter Alexis Denisof, Actor Graeme Garden, British comedy writer and performer, who

has written about his experiences with the condition Tony Gonzalez, American NFL football player Jane Greer, actress, had when 15 y/o

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The list goes on Katie Holmes, Actress Ralph Kiner, American baseball player in the 1940s and 1950s Amy Goodman, American journalist and author Curtis LeMay, was a general in the United States Air Force and the vice

presidential running mate of independent candidate George C. Wallace in 1968 Ralph Nader, American author, activist, politician Jim Ross, professional wrestling announcer for WWE RAW Rick Savage, British musician and bassist for Def Leppard Jamey Sheridan, American actor. His condition was written into the show Law

and Order: Criminal Intent and his character Captain James Deakins also had Bell's palsy.

Joseph C. Wilson, American diplomat Milo Ventimiglia, Actor

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THANKS

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