BELL’S PALSY

J.SARAVANAN
 SIR CHARLES BELL

Scottish surgeon , UK

First described this palsy

Most common cause of facial palsy

worldwide
 DEFINITION
ACUTE IDIOPATHIC UNILATERAL(COMMONLY)
LOWER MOTOR NEURON TYPE OF FACIAL
NERVE PALSY DUE TO NON SUPPURATIVE
INFLAMMATION WITHIN THE FACIAL CANAL
ABOVE THE STYLOMASTOID FORAMEN
 FUNCTIONAL COMPONENTS OF
FACIAL NERVE
• SPECIAL VISCERAL AFFERENT :Taste sensation
• GENERAL SOMATIC AFFERENT: Sensation
from posterosuperior ear
canal,concha,tympanic membrance
• SPECIAL VISCERAL
EFFERENT:Stapedius,Digastric, stapedius,facial
expression muscles
• GENERAL VISCERAL EFFERENT: Secretomotor
To SUBMANDIBULAR GLAND, SUBLINGUAL,
LACRIMAL GLAND and GLANDS OF NOSE,PALATE
PHARYNX
• GENERAL VISCERAL AFFERENT: Afferent
impulse from submandibular, sublingual,
glands in nose., palate and pharynx
 NUCLEUS
• FACIAL MOTOR NUCLEUS : deep in reticular
formation of LOWER PONS. Receive fibres
from Precentral gyrus and THALAMUS (
Involuntary control of facial muscles)
• SUPERIOR SALIVATORY NUCLEUS
• LACRIMATORY NUCLEUS
• NUCLEUS OF TRACTUS SOLITARIUS
FACIAL NERVE COURSE

3 PARTS
INTRACRANIAL

INTRATEMPORAL

EXTRACRANIAL
 INTRATEMPORAL SEGMENTS
• MEATAL - within interal acoustic meatus
• LABRYINTHINE- upto geniculate ganglion
turns posteriorly to form GENU
SHORTEST NARROWEST SEGMENT
• TYMPANIC - horizontal segment upto
pyramidal prominence
• MASTOID or VERTICAL segment - upto
stylomstoid foramen Second genu occur
FACIAL NUCLEUS
BRANCHES OF FACIAL NERVE
 UMN LESION LMN LESION

Upper face escapes Total face.

Bell’s phenomenon – absent bell’s phenomenon – present.

Taste and corneal reflex preserved. Loss of taste and corneal reflex.

Emotional fibres not affected Emotional fibres affected

Long tract signs present. Long tract signs absent.

UMN LESION LMN LESION

UNILATERAL : UNILATERAL :
Usually vascular multi infarct dementia
Cerebral tumour Motor neuron disease
Multiple sclerosis Pseudobulbar palsy
Double Hemiplegia
BILATERAL : BILATERAL :
Bell’s Palsy Gullian barre syndrome
Parotid tumour Sarcoidosis
Head Injuries Leprosy
Skull base tumours Leukemia
Diabetes Diabetes mellits
Basal meningitis
lyme’s disease
Bulbar palsy
 CAUSES OF BELL’S PALSY
• Diabetes mellitus
• Herpes simplex I infection
• Exposure to cold
• Hereditary-narrow facial canal(positive family history)
• Other viruses-Herpes zoster,Adenovirus,Mumps
virus,Cowsackie virus
• Post intranasal influenza vaccine due to Escherichia coli
enterotoxins used as adjuvant (or)
Reactivation of latent virus
 CLINICAL FEATURES OF BELL’S PALSY

Sudden onset and maximum weakness on

Second day after palsy. Pain behind the ear
may precede the paralysis.
BELL PHENOMENON
 TEST FOR FACIAL MUSCLES
• OCCIPITO FRONTALIS - loss of wrinkling on
forehead
• ORBICULARIS OCULI – close eye tightly and try
to open the eyes
• BUCCINATOR – Ask him to puff cheek out
• ASK TO SMILE– For zygomatic , Levator and
depressor anguli oris , buccinator and risorius
 COMPLICATIONS
• SOCIAL EMBARRASMENT
• EXPOSURE KERATITIS prevented by artifical tear
drops ,antibiotic drops and eye padding during
sleep. Tarsorrhaphy is performed.
• CONTRACTURES Fibrosis of atrophied muscle
Leading to fixed contraction of muscle
• CROCODILE TEAR regeneration of secretomotor
to lacrimal gland. Treated by section of greater
petrosal nerve or tympanic neurectomy
• JAW WINKING - movement of angle of
mouth with eye closure

• HEMIFACIAL SPASM

• BLEPHAROSPASM – Functional blindness

INVESTIGATIONS
It’s a clinical diagnosis.
Absence of cutaneous lesions of zoster in ear canal.
All other cranial nerves – normal.
PROGESSING LESION
Involvement of chorda tympani
Involvement of nerve to stapedius
BAD PROGNOSTIC SIGN
Electromyography - If shows denervation after 10 days. There will be
delay of 3 months of delay before regenaration and it may be incomplete.

GOOD PROGNOSTIC SIGN

Presence of incomplete paralysis in first week after palsy.
 DIFFERENTIAL DIAGNOSIS
• Ramsay hunt syndrome
• Lyme disease from endemic area
• Bilaterally occur in Guillain Barre syndrome
and sarcoidosis
• Leprosy, Diabetes mellitus ,Connective tissue
disorder
• Recurrently Melkersson Rosenthal syndrome
 MEDICAL TREATMENT
• PREDNISOLONE 1mg/kg upto 80mg/day
during first 5 day. Then tapered another 5
days. Ideally start within 72 hours
• Acyclovir 400mg 5times/ day for 10 days
Valacyclovir 1g/day for 5-7 days
• Gentle massage over paralysed side
• Eye padding during sleep, local antibiotic
drops used if congestion is seen
• Facial exercise is advised
• Sometimes parental vitamin can be given
• Facial stripping
• Galvanic current stimulation of paralysed side
 SURGICAL TREATMENT
• Nerve decompression
• End to End anastomosis
• Nerve graft - Greater auricular nerve, lateral
cutaneous nerve of thigh and Sural nerve
• Hyoglossal Facial Anastomosis
• Plastic procedure
INCOMPLETE RECOVERY BAD PROGNOSTIC SIGN

Completed palsy at beginning

Residual paralysis
Delayed recovery
Hemifacial spasm
Co morbid History – Diabetes ,
Crocodile tears Hypertension

Unwanted facial movements Hyperacusis and Loss of taste sensation

closure of eyes with movement of
mouth Severe axonal degeneration on Electro
myography after 10 DAYS
THANK YOU