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Bell's Palsy Case Report.pptx
- 1. Bell’s Palsy
- 2. CASE N.C 57/female who developed sudden right facial drooping and weakness which was associated with 3 days onset of fever (38 deg C). She was referred to rehab service for co-management.
- 4. History of Present Illness: • What is the laterality of the facial weakness? • Ask about the evolution of weakness. Is it sudden or slowly progressive? • When did the symptoms started? Is the fever associated with other symptoms such as cough, colds, headache, dizziness, myalgia? • Ask about preceding viral infections or trauma to the head or face • How long was the patient experiencing the symptoms? • Is the patient experiencing the following? Inability to close the eyelid or lip on the affected side Difficulty in raising the eyebrow Loss of taste sensation or altered taste Hypersensitivity to loud noises, Reduced hearing, Ear pain Dryness in the affected eye or mouth Drooling and Excessive tearing in the affected eye Facial pain
- 5. Functional History: Are all body parts present, well-formed, and in the right location? (Assessing Impairment) Are all physiologic functions working well? What functional deficits are present as a result of this injury? Can the patient do common activities of daily living? Is there difficulty in eating, drinking, and speaking? (Activity Limitation) Can the patient perform the same tasks or activities in their usual environment e.g. home, workplace, community? (Participation Restriction)
- 6. Past Medical History Are there any pre-existing illnesses such as diabetes and hypertension? Is there a previous history of Upper respiratory tract infection or any viral infections? Previous history of having chickenpox? Did the patient have previous fractures, surgeries, and hospitalizations? Are there medications that the patient is taking? Ask for the patient's vaccination history (COVID-19, Flu, MMR vaccine)
- 7. Social History: What about the patient’s home environment and living circumstances? Does she have family and friends as support system? What is the occupation of the patient? What are the patient’s recreational activities? Is the patient a smoker and alcoholic beverage drinker? Ask for the patient’s sexual history Ask also for the patient’s OB history. Is she pregnant?
- 8. Family Medical History Do they have any heredofamilial diseases? (Diabetes, Hypertension, Stroke, Cancer) Family history of Bell’s Palsy?
- 9. Review of Systems Are there any problems or disease in various systems not mentioned in the history? • General: (fever, weight loss/gain, fatigue, poor appetite) • Skin: problems with the skin? Sores? Rashes? Pruritus? Dryness? • HEENT: changes in vision, hearing, and smell, swelling? Bleeding? Diplopia? • Pulmonary: difficulty breathing? Cough? Hemoptysis? Pleuritic chest pain? • Cardiovascular: chest pain? Palpitations? Swelling of extremities? Fatigue? • Gastrointestinal: changes in digestion and bowel habits? Diarrhea? Nausea/vomiting? • Genitourinary: problems with urination? Pain? Frequency? Urgency? Nocturia? • Endocrine: fatigue? Changes in skin or hair? Frequent urination? • Musculoskeletal: joint or muscle pain? Weakness? Stiffness? Limitation of motion? • Nervous: pins and needles sensation?
- 11. Focused Physical Examination – CN VII I. MOTOR • Inspection – Check for the symmetry of the face, involuntary movements, and any signs of facial weakness such as loss of facial wrinkles, flattening of the nasolabial fold, and blink pattern. - The patient is asked to wrinkle the forehead (Frontalis), close the eyes (orbicularis oculi), puff out both cheeks (buccinator), and smile while showing the teeth (orbicularis oris). • Bell's phenomenon – The eyelids will not close and the lower lid sags; on attempted closure, the eye rolls upward • Facial synkinesis – involuntary movements of the facial muscles II. SENSORY • Taste function – to evaluate the 4 fundamental tastes in anterior 2/3 of the tongue. • Otologic Examination – Inspection of external auditory canal (vesicles, injection or erythema, infection, or trauma). – Otoscopy and Tuning fork examination
- 12. Focused Physical Examination – CN VII III. NEUROLOGIC • Mental Status Examination • Cranial Nerves Examination • Motor, Sensory, Reflexes, and Cerebellar System • Cerebral Function
- 14. Approach to Diagnosis Right Facial Weakness Peripheral/ Lower Motor Neuron Lesion Central/ Upper Motor Neuron Lesion 57/F
- 15. Rule IN Rule OUT (+) Unilateral facial drooping and weakness (+) Involvement of the forehead (-) Slow, progressive weakness (-) Involvement of extremities (-) History of hypertension Stroke Neoplastic/Tumor Rule IN Rule OUT (+) Unilateral facial drooping and weakness (-) Gradual Onset (-) Mental Status changes (-) Past medical and Family history of cancer CentralNerveLesions
- 16. Rule IN Rule OUT (+) Unilateral facial drooping and weakness (with involvement of the forehead) (+) Fever (-) Associated symptoms such as cough, colds, rashes, arthralgias Cannot be totally ruled out without further diagnostic examinations Viral Infections Bell’s Palsy Rule IN Rule OUT (+) Unilateral facial drooping and weakness (with involvement of the forehead) (+) Fever Cannot be ruled out Peripheral Nerve Lesions
- 17. Primary Impression Right Lower Motor Neuron Facial Palsy (Bell’s Palsy) Etiology: Idiopathic vs. Viral
- 18. Bell’s Palsy vs. Stroke
- 20. Management
- 21. DIAGNOSTICS Routine Studies (Complete blood cell (CBC) count, Inflammatory markers, Fasting blood glucose) These are ordered to rule out viral infections, diabetes mellitus, and inflammatory conditions Imaging Magnetic resonance imaging (MRI) or computerized tomography (CT) may be needed on occasion to rule out other possible sources of pressure on the facial nerve, such as a tumor or skull fracture. Electrodiagnostic (EMG- NCV) Standard procedure to confirm the presence of nerve damage and determine its severity.These tests are useful to confirm the diagnosis, establish baseline results, determine severity, and rule out other potential causes. Lumbar Puncture To rule our other potential causes
- 22. THERAPEUTIC S Pharmacologic • Oral corticosteroids is recommended to reduce facial nerve inflammation in patients with Bell's palsy. - Prednisone (60 to 80 mg/day) for one week • Oral vitamin B-6 supplements may be helpful for mild symptoms. This treatment should be carried out for 6-12 weeks, depending on patient response. • Antiviral therapy (severe facial palsy) - Acyclovir or Valacyclovir
- 23. Supportive • Eye Care - Using artificial tear drops in order to prevent dryness of eyes and corneal injury. - Protective glasses or goggles can be worn to physically protect the eye from external trauma.
- 24. Rehab management 1. Electrotherapy (Electrical Stimulation & Laser Therapy) • To re-establish facial control and movement • It prevents muscle atrophy and promote tissue healing and therefore may help prevent sequelae of Bell's palsy. • Also useful to diminish pain, muscle weakness, and facilitate muscle movement.
- 25. Rehab management 2. Facial Muscle Exercises and Massage • Eye closing exercise - Improve lubrication of the eye to decrease eye dryness and strengthen the eye lid muscles • AAROM (smile, eyebrow raise, frown, pucker lips, scrunching face) - may help to improve facial muscular functions
- 26. References • The Physiatric History and Physical Examination by Michael W. O’Dell, C. David Lin, J. Ricky Singh, and George C. Christolias • Tiemstra, J. D., & Khatkhate, N. (2007, October 1). Bell's Palsy: Diagnosis and Management. American Family Physician. Retrieved August 23, 2022, from https://www.aafp.org/pubs/afp/issues/2007/1001/p997.html • De Almeida JR, Guyatt GH, Sud S, Dorion J, Hill MD, Kolber MR, Lea J, Reg SL, Somogyi BK, Westerberg BD, White C, Chen JM; Bell Palsy Working Group, Canadian Society of Otolaryngology - Head and Neck Surgery and Canadian Neurological Sciences Federation. Management of Bell palsy: clinical practice guideline. CMAJ. 2014 Sep 2;186(12):917-22. doi: 10.1503/cmaj.131801. Epub 2014 Jun 16. PMID: 24934895; PMCID: PMC4150706. • Patel, D., & Levin, K. (n.d.). Bell Palsy: Clinical Examination and management. Bell palsy: Clinical examination and management. Retrieved August 22, 2022, from https://www.ccjm.org/content/ccjom/82/7/419.full.pdf
- 27. Thank you!
Editor's Notes
- Closely observe the blink pattern, as the involved side in Bell palsy may slightly lag behind the normal eye, and the patient may be unable to close the eye completely. In Bell palsy, when the patient attempts to close the eyes, the affected side shows incomplete closure and the eye may remain partly open. Ask the patient to hold air in the mouth against resistance. This assesses the strength of the buccinator muscle. Ask the patient to pucker or purse the lips and observe for asymmetry or weakness on the affected side. Test the orbicularis oris muscle by trying to spread the lips apart while the patient resists, and observe for weakness on one side. Facial synkinesis – involuntary movements of the facial muscles – usually occurs after injury to the facial nerve In Bell palsy, wrinkling of the forehead on the affected side when raising the eyebrows is either asymmetrical or absent. If the forehead muscles are spared and the lower face is weak, this signifies a central lesion such as a stroke or other structural abnormality and not a peripheral lesion of the facial nerve (eg, Bell palsy). We also need to evaluate any abnormalities in taste since the facial nerve supplies taste fibers to the anterior two-thirds of the tongue. Taste may be assessed by holding the tongue with gauze and testing each side of the tongue independently with salt, sugar, and vinegar. The mouth must be washed after testing with different substances. The affected side has decreased taste compared with the normal side. An otologic examination includes otoscopy and tuning fork examination can also be done. The external auditory canal must also be inspected for vesicles, injection or erythema, infection, or trauma.
- We also need to do a thorough neurologic examination such as the in order to rule out other pathologies.
- To approach the diagnosis, here we have a 37/F with a chief complaint of right facial weakness. In order to know what exactly is the cause of the facial nerve injury, it it important to Determine first the location of the lesion whether it is the UMN or the LMN
- In Central/ Upper Motor Neuron facial palsy, the problem is in the corticospinal tract above the nucleus of CN VII in the pons. Therefore, there will be paralysis on the lower half of the face only sparring the forehead. For the first differential, we have stroke which was ruled in due to the clinical presentation of the patient which is unilateral facial drooping and weakness However, it was ruled out since there is involvement of the forehead and the onset of symptoms for the patient is sudden. There’s also no mentioned history of hypertension as well as involvement of the extremities. Next is neoplastic or tumors. It was also ruled in due to the presence of unilateral facial weakness. But was ruled out since neoplastic conditions usually have a gradual onset, and there’s changes in mental status of the patient as well as involvement of the extremities. There’s also no past medical and family history of cancer.
- In Peripheral/ Lower Motor Neuron facial palsy – there’s paralysis of Entire Half of the face including the Frontalis, eyelid and nasal fold is weak Next differential is viral infections, Although the cause is unknown or idiopathic, according to studies, the major cause of Bell palsy is believed to be viral infections such as herpes simplex, herpes zoster, HIV,
- Determining the location of the lesion is important in differentiating the two. In central facial palsy, paralysis is contralateral to the lesion, and eyelid and forehead muscles are not affected. If the forehead muscles are spared and the lower face is weak, this signifies a central lesion such as a stroke or other structural abnormality and not a peripheral lesion of the facial nerve (eg, Bell palsy).
- The House-Brackmann Scale is one of the most commonly used tool for the clinical evaluation of facial nerve function. The scale is based upon functional impairment, ranging between I (normal) and VI (no movement).
- The mainstay of pharmacologic therapy for Bell's palsy or facial nerve palsy is the oral corticosteroid treatment. In severe acute cases, combining antiviral therapy with glucocorticoids may improve outcomes.
- The mainstay of pharmacologic therapy for Bell's palsy or facial nerve palsy is early short-term oral glucocorticoid treatment. In severe acute cases, combining antiviral therapy with glucocorticoids may improve outcomes.
- Facial exercises may help to improve facial muscular functions Bell’s palsy massage is sometimes recommended as part of a facial paralysis treatment program. Initially, a massage or physical therapist teaches a patient how to massage for Bell’s palsy. Lower Facial Muscles: Mouth exercises often require a patient to grasp the center of the lips with the thumb and index finger, then push the lips toward the face and move the lips into a smile position. This helps a patient strengthen the lower facial muscles and regain the ability to naturally smile, frown, and make other facial expressions. Forehead: Massaging the upper portion of the face sometimes helps a Bell’s palsy patient reduce muscle weakness in the forehead. Cheeks: Using the fingertips to perform a circular motion around the cheeks may help a Bell’s palsy patient increase muscle movement in the cheeks.