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Bell's palsy
1.
2.
3. You wake up one morning,
and your face feels stiff and
odd. When you look in a
mirror, half your face appears
to droop. You can only
manage half a smile, your eye
is dripping tears and doesn't
want to close. What in the
world is going on?
4. Charles Bell
› Well 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
5. The 7th cranial nerve is paired
with the
structure that travels through
a narrow,
bony canal (called the
Fallopian canal) in the skull
beneath the ear
to the muscles on each side of
the face.
The nerve is mostly encased in
this bony shell.
6. 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
7.
8. Upper facial territory is supplied by bilateral motor
cortices
Lower facial territory is supplied only by contralateral
motor cortex
Therefore, unilateral central lesions spare upper face
Lesions distal to geniculate ganglion
› Mostly motor abnormalities
Lesions proximal to geniculate ganglion
› Motor, gustatory & autonomic abnormalities
9. Sunderland classification of nerve
injury
1° damage = Compression
2° damage = Interruption of axoplasm
3° damage = Disruption of myelin
4° damage = Disruption of perineurium,
myelin and axon
5° damage = Transection of nerve
10.
11. Characterized by:
› Peripheral facial paralysis
› Acute benign cranial polyneuritis
Acute disorder characterized by a
disruption of the motor branches of
cranial nerve VII on one side of the
face. (in absence of stroke)
12. 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
13. Pain or discomfort in jaw and behind
the ear
Ringing in one or both ears
Loss of taste
Headache
Hypersensitivity to sound
Impaired speech
Dizziness
Difficulty eating and drinking
14. Often accompanied by an outbreak
of herpes vesicles in or around the ear.
Pain around or behind the ear
Fever, tinnitus, hearing deficits
Flaccidity of the affected side of the
face with drooping of the mouth
accompanied by drooling DT paralysis
of the facial nerve (motor branches)
15. Inability to close the eyelids, with an upward
movement of the eyeball when closure is
attempted; lower lid may turn out
Wide palpebral fissure (opening between
eyelids)
Flattening of the nasolabial fold
Inability to smile, frown, or whistle
Unilateral loss of taste
Altered chewing ability; loss of or excessive
tearing
16.
17. 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
18. To determine the anatomical
level of a peripheral lesion
Lacrimation Geniculate
ganglion
Stapedius reflex motor nerve of
stapedius muscle
Taste chorda tympani
19. Geniculate ganglion & petrosal nerve
function test
Schirmer’s test +ve when
› Affected side shows less than half
the amount of lacrimation seen on
the normal side
› Sum of the lengths of wetted filter
paper for both eyes less than 25 mm
Lesion at or proximal to the geniculate
ganglion
20.
21. Nerve to stapedius muscle test
Impedance audiometry can record
the presence or absence of
stapedius muscle contraction to
sound stimuli 70 to 100 dB above
hearing threshold
An absence reflex or a reflex less
than half the amplitude is due to a
lesion proximal to stapedius nerve
22. Chorda tympani nerve test
Solution of salt, sugar, citrate, quinine or
Electrical stimulation
Compares amount of current require for a
response each side of tongue
Normal : difference < 20 uAmp (thresholds
differening by more than 25%= abnormal)
Total lack of Chorda tympani : No response
at 300 uAmp
Disadvantage : False +ve in acute phase of
Bell’s palsy
23.
24. It occurs when the facial nerve is swollen,
inflamed, or compressed
25. Mostly unknown
May be caused by a viral infection
› Viral meningitis
› Herpes simplex
Influenza
Headaches
Chronic ear infections
High blood pressure
Diabetes
Sarcoidosis
Tumors
Lyme disease
trauma
26. Affects 40,000 Americans each year
› Men and women equally affected
› Can occur at any age
Mostly after 15 and before 60 y/o
Occurs more often in people who:
› Are pregnant
› Are diabetic
› Have an upper respiratory infection
27. Psychological withdrawal DT
changes in appearance,
malnutrition or dehydration,
mucous membrane trauma,
corneal abrasion, muscle
stretching, and facial spasms and
contractures.
28. 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
› r/o causes of pressure on nerve
29. No real Treatment
› Symptoms usually subside
Anti-inflammatory and an antiviral
› Prednisone and acyclovir
Increases the chance of recovery
Acupuncture and surgery
› For long term paralysis
30. Hard to close eye
› Use and eye patch
› Eye drops
› Tape eye shut when sleeping
31. Corticosteroids- drug of choice
Prednisone may be started immediately!
› Best if initiated before paralysis is complete
› Taper off over 2 weeks
› Decrease edema and pain
Analgesics may be needed for pain
Antivirals : Acyclovir (Zovirax) and Famvir
because HSV is implicated in 70% of cases.
32. Outcome is good!!!
Total recovery depends on amount of damage to
nerve
Improvement is gradual
Usually start to get better after 2 weeks of onset
and most recover completely 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.
33. Clinical features
› Slower onset of symptoms
› Bilateral
› Recurrence
Numbness is not unusual
Progression beyond seven
days suggests another
cause
34. Lyme disease (borreliosis)
› Endemic areas (Northeast USA, central
Europe, Scandinavia, Canada)
› Consider in children w/atypical facial palsy
Imaging: small white matter lesions similar
to multiple sclerosis, enhancement of
facial & other cranial nerves
Bilateral facial paralysis: 25%
Important to make diagnosis early
because it is curable early w/antibiotics
35. Caused by reactivation varicella zoster virus
(herpes virus type 3)
Facial paralysis + hearing loss +/- vertigo
› Herpes zoster oticus
Two-thirds of patients have rash around ear
Other cranial nerves, particularly trigeminal nerves
(5th CN) often involved
Worse prognosis than Bell’s (complete recovery:
50%)
Important cause of facial paralysis in children
6-15 years old
36. Acute facial paralysis may result from
bacterial or tuberculous infection of middle
ear, mastoid & necrotizing otitis externa
Incidence of facial paralysis with otitis
media: 0.16%
› Infection extends via bone dehiscences to nerve
in fallopian canal leading to swelling,
compression & eventually vascular compromise
& ischemia
Immune compromised patients are at risk
for pseudomona infection
Poor prognosis (complete recovery is < 50%)
37. Most acute post traumatic facial palsies are
due to t-bone fractures
Historically fractures classified as
longitudinal or transverse with transverse
carrying risk of permanent paralysis
› Longitudinal fracture usually leads to temporary
paralysis from concussion & swelling of nerve
› Transverse fracture can lead to transection of
nerve
In all types of paralysis due to fracture,
usually the region of geniculate ganglion is
involved
38. 27% of patients with tumors involving the
facial nerve develop acute facial paralysis
Most common causes: schwannomas,
hemangiomas (usually near geniculate
ganglion) & perineural spread such as with
head and neck carcinoma, lymphoma &
leukemia
Other neoplasms can also involve the facial
nerve
› Adults: metatstatic disease, glomus tumors,
vestibular schwannomas & meningiomas
› Children: eosinophilic granuloma & sarcomas
39. Guillain-Barre Syndrome
› Ascending paralysis
Iatrogenic
› Temporal bone surgery
Excision of vestibular schwannoma
has <10% chance of paralysis
Middle ear surgeries
› Babies who required forceps delivery
>90% recovery
40. Acute episodes of facial paralysis
› Facial swelling
› Fissured tongue
“Scrotal” tongue
Very rare
Familial but sporadic
› Usually begins in adolescence
Leads to facial disfigurement
No definite therapy