Trigeminal Neuralgia and bell's palsy

TrigeminalNeuralgia
And
BellsPalsy
10/8/2020 Sujata Devkota 1

Trigeminal nerve
-5th cranial nerve
-most complex nerve
-responsible for sensation of face, motor function like
chewing ,biting etc
Sujata Devkota 210/8/2020

Trigeminal Nerve

Definition
• Neuralgia - severe pain coming from a nerve.
• “Sudden usually unilateral severe, brief, stabbing,
recurrent episodes of pain in the distribution of one
or more branches of the trigeminal nerve.
-The International association for study
of pain(IASP).

Cont’d…
•It is associated with involuntary movement of facial
muscles so there is sudden closing of eye or twitching
of mouth so it was formerly called Tics Douloureux
(painful twitch).
•Most painful condition known to human.
•It is uncommon.
•Prevalence rate is 155 cases per million.
•Age: common from 50-69 years
•Female affected twice often as male.

Etiology
1.Exact cause is unknown.
2.Degenerative or viral origin suspected.
3.Intrinsic lesions
4.Extrinsic lesions

Cont’d…
Risk factors
• Nerve compression
• Kidney insufficency
• Herpes virus infection, syphilis
• Infection of teeth and jaw
• Trauma on facial nerve
• Chemical irritation

Clinical Manifestation

Clinical Manifestation cont’d…
• Abrupt onset, extensive episodic pain(30-60sec)
• Pain rarely relieved by analgesics.
• Trigger points and attacks
• Aggravating factors
Note: Individual attacks usually affect one side of the
face at a time, lasting from several seconds to a few
minutes and repeat up to hundreds of times
throughout the day

Clinical Manifestation cont’d…
The attacks feel like stabbing electric shocks,
burning, pressing, crushing, exploding or shooting
pain that becomes intractable.
Pain from trigeminal neuralgia is so intense that patient
ponders suicide.
So,called “THE SUICIDAL DISEASE”

Diagnostic evaluation
• History taking
• Neurological examination
• Blood test - Renal function and glucose level.
• Angiography, CT scan, and MRI can identify a
causative lesion.

Management
1.Medical Management
• Anticonvulsant drug-carbamazepine, gabapentin
• Analgesic: Phenytoin(assess LFT)
• Skeletal muscle relaxant-Baclofen
• OTC analgesics: Aspirin,ibuprofen

2.Surgical management
A.Rhizotomy (rhizolysis)
• To cut anterior/posterior spinal nerve root
• Nerve fibers are damaged to block pain.
• Always causes some degree of sensory loss and
facial numbness.
• Several forms of rhizotomy are available to treat
trigeminal neuralgia.

Cont’d…
Some are:
• Radiofrequency thermal lesioning
• Microvascular decompression(MVD)
• Balloon compression
• Glycerol injections
• Stereotactic radiosurgery

Radiofrequency thermal
lesioning("RFAblation“)
-Most often performed on an outpatient basis.
-Use heat generated by radio waves to target nerves
- Thus, temporarily blocks the pain signal.
- Needle is inserted to the opening of trigeminal nerve.
-Nerve area is heated with a frequency of 500khz
-can repeat until preservation of touch.
-Symptoms may reoccur 3-4 years in half of patient.

Microvascular decompression
(MVD)
-Most invasive of all.
-Offers lowest probability that pain will return.
-Reoccurrence may be with in 12-15 years.
-Done under general anesthesia in in-patient basis.
- A small incision made through mastoid bone.
-Surgeon moves away the vessel that compress the
nerve.
Then place a soft cushion between vessel and nerve.

Microvascular decompression
(MVD)

Balloon compression
-Procedure selectively affect the trigeminal ganglion
-under general anaesthesia.
-A balloon is inflated inside the skull to compress the
ganglion and help with pain relief.
- Pain relief usually lasts one to two years.

Balloon compression

Glycerol injection
-An outpatient procedure
-Needle passed through the opening in the base of skull
where mandibular nerve exists.
- IV glycerol is injected into the area of mandibular
nerve .
- Thus numbs the nerve and reduce pain.
- May reoccur with in 1-2 years.

Glycerol injection

Stereotactic radiosurgery
(Gamma knife)
-Least invasive of all
-Uses computer imaging to direct focused beam of
radiation
- Gamma knife delivers precise, controlled beams of
radiation to the site where trigeminal nerve exit at
brain stem.
- Pain relief occurs only after several weeks.
- Pain may reoccur within 3 years.

Stereotactic radiosurgery
(Gamma knife)

Surgical management cont’d…
B. Neurectomy:
-Also called partial nerve section
-Involves cutting part of nerve.
-May be performed near the entrance point of the nerve
at the brain stem

Nursing Management
Assessment:
• History: pain, duration, severity, aggravating factors
• Nutrition status and hydration
• Anxiety and depression
• Sleep problems
• Social interaction
• Coping skills

Nursing Management cont’d…
Nursing diagnosis:
• Chronic pain related to compression of nerve.
• Imbalance nutrition, less than body requirements
related to pain during eating.
• Disturbed sensory perception related to disease
condition.

Nursing diagnosis cont’d…
• Powerlessness related to lack of control over painful
episodes.
• Knowledge deficit related to unknown disease
condition.

Expected outcomes:
• Patient will experience pain relief.
• Nutritional status will be maintained.
• Sensory perception will be improved.
• Control over painful episodes will be improved
• Knowledge level will be upgraded.

Intervention
1.Relieve pain
-Review triggering factors
-develop individualized coping.
- Take medicine regularly.
-Alternative methods of communication

2.Maintain adequate nutrition
-Chew on unaffected side
-Observe for any difficulty in eating
-Eat at room temperature.
- Appropriate diet.
- Frequent meals
-Nutritional supplements if needed.

3.Enhancing protection
-Assess corneal reflex
-Check eyes every 3-4 times
-Do not rub eyes.
-Instill artificial tears every 4 hourly.

4.Increasing control
-Relaxation techniques.
-Involve in decision making.
-Involve in ADL during pain free situation.
-Interact with other clients with same problem.

Postoperative care:
• Neurological assessment
• Assess eyes for irritation
• Artificial tears to prevent dryness.

Complications
• Anorexia and weight loss
• Dehydration
• Anxiety, fear
• Depression, social isolation, and suicidal ideation in
extreme cases.

Bell’s palsy

Introduction
• Defined as unilateral inflammation of seventh
cranial nerve which results in weakness and
paralysis of facial muscles on the affected side.
• A type of acute peripheral paralysis
• Can affect anyone at any age and sex

Epidemiology
• Most common cause of acute unilateral facial
paralysis- 60 to 75%
• Annual incidence -approximately 15-30 cases/1 lakhs
• Incidence increases with age
• Pregnancy -during 3rd trimester, increase with pre
eclampsia
• Recurrence rate -4-14%

Epidemiology cont’d…
• Diabetes -29% chance
• Right side is affected most-65%
• Bilateral -23% mostly with GBS, neurofibroma
• Both sex are affected equally
• More frequent at younger age.

Etiology
• The exact cause is unknown.
• Possible causes include autoimmune diseases,
vascular ischemia.
• Tumor ,trauma on facial nerve.
• Viral diseases like herpes zoster, simplex
• Gullian barre syndrome.

Bell’s palsy

Clinical features
• Most experience a viral infection 1-2 weeks before
onset of symptoms.
• Facial paralysis: acute onset, weakness all over face
• Mouth: diminished taste, drooling ,lagging angle of
mouth

Clinical features cont’d…
• Eye: decreased blink reflex, decreased or increased
lacrimation, inability to close eyes, painful eye
sensation, photophobia, drooping of eyelid.
• Hyperacusis on the affected side.

Diagnostic procedure
• History taking- previous illness, onset of paralysis
• Physical examination: evaluation of 7th cranial nerve
function, corneal sensation
• Neurological assessment: complete examination of all
of the cranial nerves and cerebellar testing

Diagnostic procedure cont’d…
• Blood test for sugar and kidney function test.
• Lumbar puncture(LP) for CSF analysis.
• CT scan and MRI
• Electromyography and nerve conduction velocities

Medical management
• Main goal is to maintain muscle tone of the face.
• Spontaneous recovery occurs with in 3-5 weeks in
most patients.

Medical management cont’d…
• Steroid therapy- Prednisolone
-early administration has good prognosis
• Analgesics-NSAIDS for facial pain
• Hot/warm compression in the involved side.
• Proper eye care.

Medical management cont’d…
• Physiotherapy –wrinkling forehead, squeeze eyes,
purse lip, blowing out cheeks, whistling, etc
• Electrical stimulation in face.
• Surgical exploration in case of tumor.
• Biofeedback techniques is effective

Surgical management
Only indicated when other measures fail.
• Anastomosis of CN VII to CNXI or CNXII
• Closure of eyelid (Tarsorrhaphy).

Nursing management
1)Assessment:
• Medical history: risk factors
• Physical examination: pain , disturbed body
image, corneal integrity, nutritional status,
patient’s knowledge level

Nursing management cont’d…
2)Diagnosis
• Pain on the affected side related to disease condition.
• Disturbed visual perception related to impaired
corneal integrity.
• Disturbed body image altered facial expression
secondary to bell’s palsy.

• Knowledge deficit related to newly diagnosed
disease.
• Risk for impaired nutritional status related to
difficulty in chewing secondary to bell’s palsy.

3)Expected outcome
• Patient will experience pain relief.
• Corneal integrity will be maintained.
• Patient will demonstrate positiveness towards body
image.
• Patients level of understanding will be improved.
• Patient’s nutritional status will be maintained.

4.Intervention:
• Relieving pain-medications, moist heat, facial
massage
• Protecting corneal integrity- artificial tears
and ointments, eye patches, sunglasses,
frequent inspection

• Enhance body image-explore feelings, use of mirror
• Diet and nutrition-chewing on unaffected side,
balance diet, frequent mouth care
• Patient education-use of sunglass, eye shield at
night, medications, warm face.

Complication
• Excessive dryness may lead to infections ,ulcers and
even blindness.
• Synkinesis

Synkinesis

References
• Black, J.M., and Hawks, J.H.,(2009), Medical
Surgical Nursing, volume 2, pp 1886-1890
• BT, Basavanthappa., (2003) Medical Surgical
Nursing, (1st ed.),pp 586-590
• Smeltzer, S.C., Bare, B.G.,(1996)Textbook of
medical surgical nursing,(8th ed.), pp 1815-1818
• Baniya, T.U., and Aryal, Kalpana.P.,(2013)
Neuroscience Nursing (1st ed.),pp 188-194
• Sharma , M., Paudel, K., and Gautam, R.,(2074),
Essential text book of medical and surgical nursing,
(2nd ed.), Samiksha publication, pp 367-370Sujata Devkota 5710/8/2020

Cont’d…
• Suzanne, SC., Brenda, B.G., Janice, H.L. and Kerry,
HC., (1973), Brunner and Suddharth’s Textbook of
Medical Surgical Nursing, (12th ed.),volume II, pp
1521-1522,1522-1523
• Topic bell’s palsy retrieved on 22nd 2020
https://www.healthline.com/health/bells-palsy
• Topic bell’s palsy management retrieved on 22nd
2020https://www.nursingpath.in/2018/05/bells-palsy-
management-and-nursing-care.html

Trigeminal Neuralgia and bell's palsy

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