Bells Palsy

Marthin Tori
KSM Neurologi RSUD dr. Doris Sylvanus P.Raya 2018
Introduction
• The condition is named for the Scottish
surgeon who first described it in the 1800s,
Sir Charles Bell

• In the 19th century he published his discovery that the facial

nerve innervates the facial muscles that give facial expression.

• He further more reported that the trigeminal nerve mainly is

responsible for facial sensation and described several cases of
facial paralysis due to trauma or infection
 Definition

Bell palsy is an idiopathic peripheral nerve

disorder involving the facial nerve (cranial
nerve VII) and manifesting as acute, ipsilateral
facial muscle weakness with pain, abnormal
taste, and reduced tearing.

Patel D, Levin K. Bells Palsy :Clinical examintaion and Management. Cleavelnd Clinic Journal of Medicine. July 2015. Vol 82;7
 Epidemiology

• It affects 20–30 persons per 100 000 annually

• women who are pregnant and diabetics higher risk
• Both genders tend to be affected equally
• The peak age for Bell’s palsy onset is during the third
and fourth decades of life (between 20 and 40 years
of age)

Cormier J. Bell”s Palsy : A common Cause of Facial Paralysis. Texas EMS Magazine . November/Desember 2012
Anatomy Facial Nerve
Mullen MT, Difereciating Facial Weakness Caused by Bell’s Palsy VS Acute Stroke. JEMS. May 2014
Periperal Facial Palsy
Etiology
The etiology of Bell's palsy is unknown but the most possible

pathomechamism are :

Greco. A et al. Bell’s Palsy and Autoimmunity. Autoimmunity Reviews 12 (2012) 323-328
 Vascular Ischemia

possibly spasm of The suffocation of Compression

triggered by arterioles nutrients would against the
cold induce a secondary
temperature or
nourishing ischemia and facial canal
psychosomatica the facial incite edema of the and engender
nerve a facial palsy.
lly, nerve

Pham V, Young D, Makishima T. Bell's Palsy. Grand Rounds Presentation, Department of Otolaryngology The University
of Texas Medical Branch (UTMB Health). October 2012
 Viral Infection
Latent herpes viruses
Virus infection (herpes
with herpes
inflammation of
Reversible
simplex, 1 neurapraxia,
herpes
simplex type
ultimately
may predominantly
zoster) which
or herpes
been found postmortem in a
and
has
zoster
in fibers
occur if the
collection of cranial nerve
the facial nerve
immune
called thesystem
wallerian
compromised
is simultaneously
degeneration
geniculate
being reactivated
ganglion

Her
pes
vir
use
s
hav
e
bee
n
det
ect
ed
by
pol
ym
era
se
cha
in
rea
ctio
n
(PC
R)
wit
hin
the
faci
al
ner
ve

Kes VB et al. Peripheral Facial Weakness (Bell’s Palsy). Acta Clin Croat 2013;52: 195-202
Immunological hypothesis

cell-mediated autoimmune mechanisms may be of importance in the pathogenesis of Bell's palsy.

Bell's palsy
Bell's palsy patients
patients had
had aa significant
significant increase
increase in
in the
the percentage
percentage of
of B
B lymphocytes
lymphocytes and
and aa significant
significant decrease
decrease in
in the
the
percentage of
percentage of T
T lymphocytes
lymphocytes

A viral
A viral infection
infection may
may prompt
prompt an
an autoimmune
autoimmune reaction
reaction against
against aa component
component ofof the
the peripheral
peripheral nerve
nerve myelin,
myelin, leading
leading to
to the
the
demyelination of
demyelination of cranial
cranial nerves,
nerves, especially
especially the
the facial
facial nerve,
nerve, in
in aa way
way that
that is
is not
not yet
yet clear
clear

Greco et al.Bells Palsy and Autoimmunity. Autoimmunity reviews 12 (2012) 323-328

Pathophysiology

Kes VB et al. Peripheral Facial Weakness (Bell’s Palsy). Acta Clin Croat 2013;52: 195-202
Diagnosis
History :
 Acute onset of unilateral upper and lower facial paralysis
(over a 48-h period), patient complain a poor eyelid
closure ,aching of the ear or mastoid, Alteration of taste ,
Tingling or numbness of the cheek/mouth and sometimes
Blurred vision
 History of activity or job that had been done at night, outside

 inquiry on exposure to various viruses (herpes, chicken pox-

varicella zoster, HIV, etc) and history of stress and cold
symptoms.
Physical Examination

Patel D er al. Bell Palsy : Clinical Examination and Managemnet. CCJM. 82: 7. July 2015
Signs and Symptoms
 Diagnosis Topis :
Kelainan Gangguan Hiposekresi Hiposekresi
Letak Lesi Gangguan pendengaran
motorik pengecapan saliva lakrimalis
Pons-meatus akustikus
+ + + tuli/hiperakusis + +
internus
Meatus akustikus internus- +
+ + + +
ganglion genikulatum Hiperakusis
Ganglion genikulatum-N. +
+ + + -
Stapedius Hiperakusis
N.stapedius-chorda tympani
+ + + + -

Chorda tympani + + - + -
Infra chorda tympani-sekitar
foramen stilomastoideus + - - - -
Facial Grading System
UGO FISCH
Position Score Persentage (%) Score
0, 30, 70, 100

Resting 20
wrinkle forehead 10
close eyes 30
smile 30
Whistle 10
Total

Level I : Normal (100 point) Penilaian persentase :

Level II : Mild paralysis ( 75 – 99 point),
Level III : Moderate paralysis (50 – 75 point) 0 % :Complete asymmetrical, no voluntary
Level IV : moderate – severe paralysis( 25 – 50
movement
point)
Level V : Severe Paralysis (1 – 25 point) 30 %: Symmetrical, poor
Level VI : total Paralysis (0 point) 70 %:Symmetrical, fair
100%:Symmetrical, normal
 Management

Hype Phys Acu

Eye Medicatio rbaric Sur
Protection n
oxyg
iothe punc
rapy ture gery
en

Zhao Y et al. Advances in Diagnosis and Non-surgical Treatment of Bells pallsy.Journal of Otology 10 (2015) 7-12
Eye protection
 Facial paralysis can lead to eye closure failure, which,
without timely intervention, can result in corneal
ulceration, scarring and vision loss
 Intervention is based upon judgment on the prognosis of
facial nerve function as well as the lagophthalmos
 Mild lagophthalmos : artificial tears, ointment,
humidifying cover, eyelid implant, botulinum toxin or
eyelid stitches
Medication

Antiviral
Steroid
Medication

 Oral steroids within 72 h of occurrence of Bell's palsy are strongly

recommended, while sole use of anti- viral drugs or in patients with newly
developed Bell's palsy is advised against (Baugh et al., 2013)
 Steroids can not only improve prognosis in facial paralysis, but also improve
quality of life and sleep although they do not provide pain relief
 Compared to steroids, prognosis was worse in patients receiving anti-viral
agents.
 while antivirals might have some effects in treating peripheral facial
paralysis, the effects were small.
 Medication

Tiemstra J, Khatkhate N. Bell’s Palsy: Diagnosis and Management. American Family Physician. Volume 76, Number 7. October 1, 2007
Medication

America Academy of Neurology 2012

Source:
http://www.palmettohealth.com/pharmacy/Methylpred%20Shortage%20Info.pdf
Physiotherapy

Electric
BiofeedbackMime Play
Stimulation
 FACIAL EXERCISES

Sit relaxed in front of a Gently raise eyebrows, Draw your eyebrows

you can help the movement
Wrinkle up your nose
mirror with your fingers together, frown

Take a deep breath through Gently try and move Try and keep the movement the You can use your fingers to
your nose, try and flare nostrils corners of mouth outwards same on each side of your face help. Once in position take
your fingers away and see
if you can hold that smile

Lift one corner of the mouth …. then the other

EXERCISES TO HELP CLOSE THE EYE

Gently place back of index With opposite hand gently stretch eyebrow up …. working along the
Look Down finger on eyelid, to keep brow line. This will help relax the eyelid and stop it from becoming stiff.
the eye closed

Now try and gently press Narrow eyes as if

the eye lids together looking into the sun

The Bell’s Palsy Association

www.bellspalsy.org.uk
This leaflet reproduced with the kind perm ission of L. Clapham, Superintendant Physiotherapist, Wessex Neurological Centr e, Southampton General Hospital
Surgery

Surgical options for Bell palsy include the following:

 Facial nerve decompression

 Subocularis oculi fat (SOOF) lift

 Implantable devices (eg, gold weights) placed into the

eyelid
 Tarsorrhaphy

 Transposition of the temporalis muscle

 Facial nerve grafting

 Direct brow lift

Almeida JR et al. Management of bell Palsy : Clinical Practice Guideline. CMAJ 2014
 Prognosis
 Generally very good.

 at least 70–90% of patients improve without treatment, and 95% achieve

complete functional recovery with corticosteroid treatment.
 With or without treatment, most individuals begin to get better within 2
weeks after the initial onset of symptoms and most recover completely,
returning to normal function within 3 to 6 months
 In a few cases, the symptoms may never completely disappear

 In rare cases, the disorder may recur, either on the same or the opposite
side of the face

Kanerva M. Peripheral Facial Palsy. Department of Otorhinolaryngology University of Helsinki Finland. 2008
KOMPLIKASI

Crocodile tear
phenomenon

Kontraktur Synkinesis

Hemifacial
spasm