Bells palsy

Bell’s Palsy:
PRESENTED BY-
DR NANDANI KUMARI
PG II YEAR
10/7/2013 1BELLS PALSY

Submandibular ganglion
Submandibular gland

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.

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.

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

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

 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.

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

Evaluation
 Careful history – timing
 Associated symptoms
 recurrent
 Physical exam
 CT/MRI
 Electrophysiology
14 10/7/2013
BELLS PALSY

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

 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.

 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

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.

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 face10/7/2013 19BELLS PALSY

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

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

Differential diagnosis
 Stroke
 Herpes zooster virus
 Lyme disease
10/7/2013 BELLS PALSY 22

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.

 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.

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.

Medical treatment
 Acyclovir 400 mg 5 times/day
 Famciclovir and valacyclovir 500 mg
bid

Surgical treatment
 Facial nerve decompression
 Indication
 Completely paralysis
 Appropriate time for surgery is 2-3 weeks
after paralysis.

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.
2810/7/2013 BELLS PALSY

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)

Longitudinal VS Transverse
Type of
injury
Longitudinal Transverse
Incidence 70-90% 10-20%
Site of injury Temporal ,
Parietal area
Occipital ,
Frontal area

Sequelae
 Long delay in the onset of recovery—3months
 Regeneration of nerve –2 years
 Incomplete
 Crocodile tears
 Facial spasms

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

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

THANKS
10/7/2013 34dr nandani IDS BAREILLY

Bells palsy

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