RECENT TRENDS UN THE MANAGEMENT OF BELLS PALSY

1. RECENT ADVANCES IN
MANAGEMENT OF BELL’S PALSY
Dr SANTOSH THORAT
MBBS MS SURGERY FIAGES FMAS
ASST.PROF SURGERY
B J MEDICAL COLLEGE PUNE

2. ANATOMY-
Facial nerve is 7th
cranial nerve, which is the
mixed nerve.
The fibres of the nerve arise from four nuclei in
the lower pons
1.Motor nucleus/brachiomotor
2.Superior salivatory nucleus
3.Lacrimatory nucleus
4.Nucleus of tractus solitarius
after taking origin from pons ,the course of nerve
is divided into intra cranial & extra cranial course.

4. INTRACRANIAL COURSE
• Meatal segment- No branch.
• Facial canal:
28 to 30 mm in length
Z shaped
3 segments- labyrinthine segment
- tympanic segment
- mastoid segment

7. EXTRACRANIAL COURSE
After emerging from stylomastoid foramen it
enters the posteromedial surface of parotid
gland.in the substance of gland, it divides in
terminal five branches giving motor supply to
facial muscles.
1.Temporal branch
2.Zygomatic branch
3.Upper buccal branch
4.Marginal mandibular branch
5.Cervical branch

9. FACIAL NERVE LESIONS
UPPER MOTOR NEURONUPPER MOTOR NEURON LOWER MOTOR NEURONLOWER MOTOR NEURON
•Supranuclear involvement ofSupranuclear involvement of
corticobulbar fibres.corticobulbar fibres.
•Opposite side involvement ofOpposite side involvement of
face.face.
•No involvement of upper 1/3 ofNo involvement of upper 1/3 of
face.face.
•May be associated withMay be associated with
hemiplegia on same side.hemiplegia on same side.
•Bell’s phenomenon absent.Bell’s phenomenon absent.
•Facial reflexes increased.Facial reflexes increased.
•Nuclear or infranuclearNuclear or infranuclear
involvement.involvement.
•Same side involvement of face.Same side involvement of face.
•Complete hemifacial involvementComplete hemifacial involvement
on same side.on same side.
•Crossed hemiplegia.Crossed hemiplegia.
•Bell’s phenomenon present.Bell’s phenomenon present.
•Facial reflexes decreased.Facial reflexes decreased.

10. Contd.
•Corneal and conjunctival reflexesCorneal and conjunctival reflexes
present.present.
•Facial muscles- no atrophy.Facial muscles- no atrophy.
•Plantar extensor.Plantar extensor.
•Emotional features of faceEmotional features of face
preserved.preserved.
•EMG responses normal.EMG responses normal.
•Corneal and conjunctival reflexesCorneal and conjunctival reflexes
absent.absent.
•Facial muscles- atrophy.Facial muscles- atrophy.
•Plantar flexor.Plantar flexor.
•Emotional features of face lost.Emotional features of face lost.
•Absent, reduced or fibrillation.Absent, reduced or fibrillation.

11. LOCALIZATION OF INFRANUCLEAR FACIAL NERVE
LESIONS
1. LMN facial palsy with
deafness, tinnitus
vertigo.
2. LMN facial palsy with
normal lacrimation.
3. LMN facial palsy with
normal lacrimation
and hearing.
4. Taste sensation
preserved.
5. Only facial muscles
affected.

12. BELL’S PALSY
• Described by Sir Charles Bell.
• Acute non suppurative idiopathic inflammation of
facial nerve in facial canal.
• Most common form of facial nerve lesion.
• Incidence: 25/lakh or 1 in 60 persons in a life time.
• Etiology:
i. Idiopathic- 50 – 60 %.
ii. HSV1- 25 – 30%
iii. Associated with DM/HTN in 10 – 14 % of patients.
iv. Inactivated intranasal influenza vaccine

13. CLINICAL FEATURES
• Mostly preceded by viral prodrome in 60% of cases.
• Retroauricular pain of 1 – 2 days in 40%.
• Facial numbness in 20%.
• Tongue numbness in minority of cases.
• Acute onset within hours, maximum weakness by 48
hrs.

14. Contd.
• Inability to hold air in mouth or blow or whistle
properly.
• Loss of taste sensation or hyperacusis or both
may occur.
• Corneal / conjunctival reflex is lost.

15. Contd.
Smoothening of forehead
furrows.
Wide palpebral fissure; Bell’s
phenomenon.
Lacrimation;
Loss of nasolabial furrow.
Drooping of angle of mouth
with dribbling of saliva.

17. Bell’s phenomenon

18. RECOVERY AND PROGNOSIS
• Spontaneous recovery: 70 – 80 %.
• Incomplete recovery: 10 – 12 %.
Residual facial palsy.
Hemifacial spasm.
Crocodile tears.
Jaw winking.
Fullness and roaring in ear.
• Recurrent bell’s palsy: 12 – 14 %.

19. PROGNOSTIC FACTORS
Good prognosis:
• Incomplete palsy in first week.
• Early recovery.
• Young age.
Poor prognosis:
• Severe lesion in first few days.
E.g. hyperacusis, reduced
lacrimation.
• Advanced age
• Associated with DM, HTN.
• Severe initial pain.
• EMG: done after first week.
Reduction in amplitude of AP
of facial muscle.

20. LAB EVALUATION
• CSF: lymphocytosis may be seen.
• MRI: swelling and enhancement of facial
nerve in facial canal.
• Electroneurography
• Nerve conduction velocity.
• Electromyography
• HSV may be found in endoneural sheath.

21. TREATMENT
• Physiotherapy.
1. Keep wet warm towel on face until it cools.
2. Massage facial into skin around eye, mouth
and mid face.
3. Stand in front of mirror and do facial
exercises.
4. Mouthwash after each food.
5. Splint or leukoplast for drooping of angle of
mouth.

22. PHARMACOLOGICAL THERAPY-
1.STEROIDS-
Steroids are the mainstay of treatment of Bell’s
palsy
Mechanism of action-
Inflammation & Edema are thought to cause of
pathogenesis of Bell’s palsy. Antiinflammatory
action of steroids are thought to be counter
these effect.

23. Cont……….
DOSE-
PREDNISOLONE-
1mg/ kg body weight/day is prescribed for 5 days then dose tapered over
next 5 days
SIDE EFFECTS-
 Hyperglycemia
 Edema
 Myopathy
 Peptic ulcer
 Hypokalemia
 Psychosis
Growth suppression
 Infection
 Osteoporosis

24. Cont…..
A Cochrane meta analysis of three studies comparing
steroid vs placebo therapy in bell’s palsy shows a
significant recovery rate after 3 months & 9 month
following therapy with steroids as compared to
placebo.
Proportion of patients who recovered facial function
At 3 month- with prednisolone: 83%
with placebo: 63%
At 9 month-with prednisolone : 93%
with placebo:81%
(*Salinas RA, Alvarez G, Ferreira J. Corticosteroids for
Bell's palsy (idiopathic facial paralysis). Cochrane
Database of Systematic Reviews 2004, Issue 4)

25. ANTIVIRALS-
Because of the possible role of HSV-1 in the
etiology of Bell's palsy, the antiviral drugs acy-
clovir and valacyclovir have been studied to
determine if they have any benefit in treatment.
ACYCLOVIR-
400 mg 5 times a day for 7 days
VALACYCLOVIR-
1000 mg 3 times a day for 7 days

26. ADVERESE EFFECTS-
 GI disturbance
 Headache
 Dizziness
 Elevated liver enzymes
 aplastic anaemia
PRECAUTION-
1.Renal failure
2. With nephrotoxic drug
3. Hemolytic Uraemic syndrome

27. Cont……
Cochrane(2009) meta analysed seven studies
comparing anti viral therapy vs placebo therapy
in Bell’s palsy.
1987 patients were assessed in these studies
shows no significant benefit of antiviral therapy
over placebo.

28. Combined therapy-
Cochrane meta analysed 18 studies including 2786
patients comparing steroid alone vs antiviral alone
vs steroid & antiviral combined therapy ,the results
of this analysis shows increased improvement in
facial function with use of combined therapy over
the steroid alone or antiviral therapy.
(JAMA 2 sept.2009, combined treatment for Bell’s
palsy).

29. SURGICAL TREATMENT
Surgical treatment comprises of surgical
decompression of facial nerve. It is very important
to select the time to use surgery as a mode of
treatment.In majority of cases recovery is
invariable so it is preferred to give at least 8 weeks
of medical treatment including stellate ganglion
block before going for surgery. Now a days the
timing of surgery is assessed by electro
neuronography (ENoG) which when shows 95% of
nerve degeneration, then surgical intervention is
done.

30. Cont…….
The role of surgery as a therapy for Bell's palsy is
controversial. If patients do not completely recover,
surgical treatment may be indicated
Three main surgical procedures are-
1.Facial nerve repair & nerve graft.
2.Nerve substitution
3.Muscle transposition
These procedures are not able to completely
restore normal function, but they can significantly
improve facial function and appearance

31. Other therapy
 pain – prednisolone or aspirin
 Depression – counselling
 transcutaneous electric stimulation- Galvanic
current may be used to activate nerve fibres.
 Acupuncture

32. Contd.
• Eye care: Complication may be exposure keratitis.
1. Replace with artificial tears 1 – 2 hrly during
day time and eye ointment at night time.
2. Adhesive tapes.
3. Implantation of gold wt or upper eyelid spring.
4. Implantation of cartilage.
5. Lateral tarsorrhaphy.

33. EVOLVING TREATMENT-

34. CURRENT RESEARCH-
 New antivirals –
Famciclovir
Sorivudine
 vaccination –
Against Herpes zoster & Herpes
simplex
 Neurotropic Growth factor, Neuroprotective
agent-

35. THANK
YOU