Bell’s palsy

SUBMITTED BY: TWINKLE SINGH

& KINJALIKA VARMA
 CONTENTS
1.INTRODUCTION
2.DEFINITION
3.APPLIED ANATONY
4.ETIOLOGY
5.SINGS AND SYMPTOMS
6.CLINICAL FEATURES
7.CLASSIFICATION
8.EXAMINATION
9.EVALUATION
BELL’S PHENOMENON
10.
11.PROGNOSIS
DIAGNOSIS
12.
DIFFERENTIAL DIAGNOSIS
13.
COMPLICATIONS
14.
SEQUALE
15.
TREATMENT
16.
REFERENCE
17.
INTRODUCTION

Bell’s palsy (facial paralysis) is due to unilateral inflammation of the ( CN VII Facial nerve)
seventh cranial nerve, which results in weakness or paralysis of the facial muscles on the
affected side.
That most often occurs unilaterally.
• Generally self-limiting. With or without treatment, most clients improve significantly within
2 weeks and about 80% recover completely within 3 months.
• in very rare cases the symptoms may never completely resolve or may recur.
DEFINITION

An idiopathic paresis or 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).
The name was ascribed to Sir Charles Bell, who in 1821, demonstrated the separation of the
motor and sensory innervation of the face
APPLIED ANATOMY
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
 May be caused by a viral infection :
 Viral meningitis
 Herpes simplex
 Headaches
 Chronic ear infections 
 High blood pressure
 Diabetes
 Sarcoidosis
 Tumors
 Lyme disease
 trauma
ETIOLOGY

 Nuclear lesions may vary in extent. Several types may be distinguished according to the
point in its course at which the facial nerve is injured.
 1. A lesion in the pons may involve the motor nucleus of the facial nerve along with the
abducent nerve, as the fibers of the facial nerve loop around its nucleus in the pons.
 2. When the nerve is paralysed in the petrous temporal in addition to the paralysis of the
motor nucleus, there is loss of taste in the anterior part of the tongue. The sense of hearing
is affected from paralysis of the stapedius.
 3. When the cause of the paralysis is fracture of the base of the skull, the auditory and
petrosal nerves are usually involved.
The most common cause of facial palsy is injury at or after facial nerves exit from the stylomastoid foramen (Bell’s palsy). In these cases
—
• The face looks asymmetrical even at rest and more so in the old patient than in the young.
• The affected side of the face and the forehead remains motionless, when voluntary or emotional movement is attempted.
• The creases of the forehead are smoothened out
• The eyes can be shut only by hand. Efforts to close the eye merely cause the eyeball to roll upwards until the cornea lies under the upper
lid
• The tip of the nose is drawn over towards the unaffected side
• The nasolabial fold is partially obliterated on the affected side
• The ala nasi does not move properly on respiration
• The lips remain in contact on the paralysed side, but cannot be pursed for whistling
• When a smile is attempted, the angle of the mouth is drawn up on the unaffected side, but on the affected side the lips remain nearly
closed and the mouth assumes a characteristic triangular form
• During mastication food accumulates in the cheek, from paralysis of the buccinator, and dribbles or is pushed out from in between the
paralysed lips
• On protrusion, the tongue is thrust over towards the paralysed side.
SIGNS AND SYMPTOMS

 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
.
CLINICAL FEATURES

 Incidence – 15 to 40 cases per 1 lac cases.

 Sex predilection women are more affected than men. The disease is 3.3 times
more common in pregnant women and is especially prevalent in the third
trimester or within the first week of postpartum.
 Age It can occur at any age. But more seen in the middle-aged people. Thirty-
one per cent of patients with recurrent Bell’s palsy are diabetics.
 It is unilateral but in 1 per cent of cases bilateral involvement can be seen.
• There is sudden onset, usually patient gives history of occurrence after awakening early in the morning
• Unilateral involvement of the entire side of the face is seen • Abrupt loss of muscular control on one side of the face
• Inability to smile, close the eye or wink or raise the eyebrow on the affected side • Whistling is impossible
• The corner of the mouth droops, causing drooling of saliva
• In an attempt to close the eyelid, the eyeball rolls upward so that the pupil is covered and only the white sclera is
visible. Bell’s sign.
• Inability to wrinkle the forehead or elevate the upper or lower lip
• The eye waters due to inability to close
• There is widening of the palpebral fissure, loss of blinking reflex
• There is obliteration of the nasolabial fold • The face appears distorted and mask like appearance to the facial features
• Speech becomes slurred
• Occasionally there is loss or alteration of taste.
House-Brackman (1985) Classification

 The House-Brackman (1985) classification is used for the classification of facial palsy:
 Grade I : Normal function without weakness.
 Grade II : Mild dysfunction with slight facial asymmetry with a minor degree of synkinesis.
 Grade III : Moderate dysfunctions—obvious, but not disfiguring, asymmetry with contracture and/or
hemifacial spasm, but residual forehead movement.
 Grade IV : Moderately severe dysfunction– obvious, disfiguring asymmetry with lack of forehead motion
and incomplete eye closure.
 Grade V : Severe dysfunction – Asymmetry at rest and only slight facial movement.
 Grade VI : Total paralysis – Complete absence of tone or motion.
 Prognosis is dependent on grade of severity.
  Differentiate between upper and lower motor
neurone lesion

EXAMINATION  UML: frontalis is spared allowing normal

furrowing of brow and eye blinking
 LML: all muscles of facial expression are affected
  Careful history – timing
 Associated symptoms
 recurrent
EVALUATION  Physical exam
 CT/MRI
 Electrophysiology
BELL’S PHENOMENON

Normally on closing the This is on the affected

eye ,the eyeball moves side due to ineffective
upwards and inwards. closure of the eyelids.
PROGNOSIS

 Initially unilateral facial weakness affecting all parts of the facial musculature is noticed.
 Facial Neuropathology gradually worsens over 2 to 3 days reaching a maximum in about 2 weeks.
 Remission begins within three weeks of onset in 85 per cent of cases with remainder taking as long as
six months.
 Spontaneous recovery is known to occur in Bell’s palsy.
 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.
 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
Diagnosis

 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
Differential diagnosis

 Stroke
 Herpes zooster virus
 Lyme disease
COMPLICATIONS

1.Corneal ulcerations
2. Impairment of vision
3. Psychosocial adjustment to prolonged paralysis
Sequelae

 Long delay in the onset of recovery—3months

 Regeneration of nerve –2 years
 Incomplete
 Crocodile tears
 Facial spasms
Crocodile Tear Syndrome

 Due to the injury to the facial nerve proximal to the geniculate ganglion, there may be a
misdirection of the nerve fibres to the lacrimal gland instead of going to submandibular
gland, through the greater petrosal nerve. As a result the patient lacrimates while eating.
 This paroxysmal lacrimation is termed as ‘crocodile tear syndrome’ and can be treated by
dividing the greater petrosal nerve
Treatment

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.
 Management Physiotherapy
 The effect of facial paralysis or Bell’s palsy is wasting or muscle atrophy. Physiotherapy
is therefore indicated to maintain the muscle tone and should be instituted as early as
possible.
 It consists of electrical stimuli by galvanism, gentle massage and facial exercise.
 Vitamins B1, B6, B12 may be administered.
Electrophysiology

 Measure amounts of neural degeneration occurred distal to injury by measuring muscle

response to electrical stimulus
 Able to differentiate nerve fibers undergoing Wallerian degeneration.
Surgical treatment

 Facial nerve decompression

 Indication
 Completely paralysis
 Appropriate time for surgery is 2-3 weeks after paralysis.
 TREATMENT

Open injuries of the facial nerve should be repaired surgically as soon as possible
Surgical repair of the transected facial nerve is done with direct end to end approximation and
suturing
If there is a gap between the proximal and distal part of the nerve with some part of the nerve loss—
then autogenous nerve grafting is done
a. The hypoglossal nerve has been a very effective autogenous graft for facial nerve reconstruction.
b. The sural nerve is an alternative donor
c. Branches from the cervical plexus, from the ipsilateral or contralateral side are also most
frequently used for facial nerve autografting
d. A great auricular nerve can be used
 Technique of Nerve Grafting Microsurgical techniques
 1. In primary or early secondary nerve reconstruction following injury, direct identification and
preparation of the nerve stump is possible.
 2. In secondary microsurgical nerve repair, exploration of the site of the lesion and the stumps of the
facial nerve is done. The identification of the nerve at the stylomastoid foramen is the best choice.
 At least 2 mm thick facial nerve stump is identified with the help of a nerve stimulator. The main facial
nerve and small distal branches are repaired by epineural sutures, which are technically easier and
provide less surgical trauma to the inner nerve structures.
 Depending on the nerve diameter, two, four or six 10.0 nylon sutures are given.
 End to end anastomosis can be only performed immediately following sharp injury of the facial nerve
 Surgical correction of the eyelids
 Medical treatment for protection of the cornea (ointment, taping) often fails and surgical procedures
such as tarsorrhaphy, magnetic implants and springs may be associated with infections.
 Use of prosthesis to give support to the buccal sulcus is also tried. The rim of the prosthesis distends
the lateral part of vestibule of mouth chiefly in front of the zygomatic process. This bulk is attached
to a denture. Such buccal support does a great deal to improve the appearance of the patient.
 Postoperative care Prevention of disturbance of the nerve repair area during recovery from
anaesthesia and in the first few postoperative days is important for successful nerve regeneration.
 Avoidance of talking and intake of solid food in the first 48 hours followed by minimal facial
movement for the next 5 days is emphasized.
 Nerve decompression—can be carried out internally or externally.
 • Internal decompression—the nerve is exposed in the fallopian canal and pressure in the
canal is relieved by exposing the nerve and the epineural sheath is opened to visualize the
nerve fibres and release adhesions or re-establish continuity.
 • External decompression—is done by releasing of epineural sheath from surrounding scar
tissue, bone or a foreign body.
 • Nerve anastomosis—Reanimation—anastomosis of the central end of hypoglossal or
spinal accessory nerve with the distal end of the facial nerve is done.
 • Nerve grafting—whenever there is evidence of neuroma or loss of portion of a nerve,
nerve grafting can be considered.
REFERENCES

 1. BD CHAURASIA
 2. NEELIMA MALIK
 3. GOOGLE