Mrs. R.M., a 25-year-old housewife, presented with difficulty moving the muscles on the right side of her face. She was diagnosed with Bell's palsy by her doctor after experiencing pain in her teeth and noticing drooping on the right side of her face. On examination, her right orbicularis oculi, buccinator, zygomaticus, platysma, and orbicularis oris muscles were found to be weakly functional. The physical therapist assessed that she had weakness of the right facial muscles resulting in inability to fully close her right eye and facial asymmetry. The goals of treatment were to improve strength and function of the right facial muscles over 12 sessions to allow her to

1. Case Pre
Bell’s Palsy

2. On July 19, 2019, Mrs. R.M. a 25 year-old,
living in Manolo Fortich, Bukidnon came to
NMMC Department of Rehabilitation Medicine
Physical Therapy Section w/ a complaint of
difficulty in moving facial muscles on the R
side of face.

3. Demographics
Name: R.M.
Weight: 54 kg
Height: 160 cm
Occupation: housewife
Referring MD: (name unrecalled)
Referring Dx: Bell’s Palsy R

4. Chief Complaint:
Px stated, “Dili kaayo nako malihok.”
(referring to her R side of her face)
“Paralyze ni.”

5. Hx of Present Illness
July 06, 2019, Px c/o pain beginning on her
teeth progressing to a HA & when she checks
herself in the mirror she noticed drooping on
her R side of face
July 13, 2019, she goes for a check-up w/ a
doctor @ Philips Memorial Hospital & was by
Dr. (name unrecalled). Px underwent ancillary
procedures & was Dx w/ Facial N. Palsy. She
was then referred to NMMC

6. Current Medication
Prednisone
multivitamins

7. Family Hx
paternal maternal
(+) HTN (-) HTN
(+) diabetes (-) diabetes

8. Personal & Social Hx
Living w/ husband, in-laws, & 2 children

9. Maternal Hx
Recently give birth to a baby, 2 mo ago

10. Bell’s Palsy
What is it?
Is a dysfunction of the facial nerve
Usu. unilateral

11. Anatomy & Physiology

13. Intracranial Part

14. Intracranial Part
Branchiomotor nucleus
Branchiomotor fibers

15. Intracranial Part
Facial colliculus

16. Intracranial Part
Superior salivatory
nucleus
Parasympathetic fiber

17. Intracranial Part
Nucleus tractus
solitarius
Taste fibers

18. Intracranial Part
Spinal nucleus
Of CN 5
Somatic afferent fibers

19. Intracranial Part
Pontomedullary junction

20. Intracranial Part
Sensory component
Or
Nervus intermedius

21. Internal acoustic meatusPosterior
cranial
fossa
Geniculate ganglion
Middle cranial
fossa
Facial canal

22. Stapedius ms
stapes
posterior
auricular
branch
Styloid process
Mastoid process
Stylomastoid foramen

23. posterior
auricular
branch
stylohyoid
Posterior
belly of
digastric
Parotid
gland
Temporal branch
zygomatic
buccal branch
Marginal mandibular branch
cervical branch

27. Etiology
Uncertain
Exposure to cold
Swelling of the nerve

28. Epidemiology
Equally affects men & women
Increased incidence in pregnant women

29. Pathophysiology
Inflammation
of Facial
Nerve
Edematous
surrounding
tissues
Nerve
compression
Bell’s Palsy

30. Site of lesion:
Stylomastoid
Paralyzes of all muscles of facial muscle
Saliva may dribble from the corner of the
mouth
Px complains of heaviness/numbness &
sometimes an aching in the face

31. Site of lesion:
Chorda tympani
Loss of taste over anterior 2/3 of tongue on
same side

32. Site of lesion:
Stapedius ms
hyperacusis

33. Site of lesion:
Geniculate ganglion
Decrease lacrimation
Decrease salivation

34. Test & Measures

35. FMT
F – Functional
WF - Weak Functional
NF - non-functional
0 - absent

36. FMT
muscle action R side L side
Corrugator
supercilli
Vertical wrinkling of
forehead
F F
occipitofrontalis Raising the
eyebrows
F F
Orbicularis oculi Closes eyes WF F
procerus Wrinkling of
nosebridge
F F
nasalis Nasal flaring F F
buccinator Compresses cheek WF F
zygomaticus smile WF F
platysma frown WF F
Orbicularis oris Closes lips WF F

38. R side L side

39. R side L side

40. R side L side

41. If R side is affected:

42. If R side is affected:
R side L side
okay
okay
Still okay
Not okay

43. If R side is affected:
R side L side
okay
okay
Still okay
Not okay

44. Special Test
(+) Bell’s Phenomenon
Taste test not performed.

45. Prognosis/complications
Most patients recover in 4-8 weeks w/o
treatment
Residual face asymmetry may require
corrective surgery
Incomplete paralysis indicates good
prognosis
Patients w/ complete paralysis, electrical
absence on EMG is an optimistic sign
Occasional aberrant re-innervation occurs:

46. Jaw winking

48. Crocodile tears syndrome
shedding of tears while eating or drinking
in patients recovering from Bell’s Palsy.
It is also referred to as gustatory
lacrimation

49. PT Impression
Px presents w/ WF R Orbicularis oculi,
buccinator, zygomaticus, platysma, &
orbicularis oris resulting to inability to fully
close R eye & facial asymmetry. Hence,
leading to discomfort in doing ADLs &
IADLs

50. Problem List
WF R orbicularis oculi, buccinator,
zygomaticus, platysma, & orbicularis oris

51. Long-term goal
Px will be able to do housechores &
take care of her children w/o discomfort in
12 PT sessions

52. Short-term goal
Px will have increase FMT on R
orbicularis oculi, buccinator, zygomaticus,
platysma, & orbicularis oris from WF to F
in 6 PT sessions

53. PT Management
1) IRR R side of face x 15 min
2) ES on R facial motor points x 30
contractions x 3 sets
3) Facial massage x 5 min
4) Facial ms ex x 10 SH x 10 reps
5) HEP