Bell’s PalsyBell’s PalsyBell’s PalsyBell’s PalsyBy: Olivia HarrisBy: Olivia Harris

INtroductionINtroduction

A form of facial paralysis that causes dysfunction of the facial cranial nerve and makes it so that you no longer have control over your facial muscles. It is usually on one side of the face and for our case study it was on her right side.

What does it look like?

A form of facial paralysis that causes dysfunction of the facial cranial nerve and makes it so that you no longer have control over your facial muscles. It is usually on one side of the face and for our case study it was on her right side.

What does it look like?

Facial Nerve (Taylor, 2012)Facial Nerve (Taylor, 2012)

Controls the muscles of the face.

Allows us to smile, cry, wink, frown, open our mouths, open our eyes, etc..

Everyone has two for each side of the face.

Muscles controlled by the Facial Nerve

stapedius

stylohyoid

mylohyoid

posterior belly digastric

Also controlled by the Facial Nerve

Taste in the anterior 2/3 of the tongue

Lacrimal, Submandibular, Sublingual gland, nasal, and palatine glands

Controls the muscles of the face.

Allows us to smile, cry, wink, frown, open our mouths, open our eyes, etc..

Everyone has two for each side of the face.

Muscles controlled by the Facial Nerve

stapedius

stylohyoid

mylohyoid

posterior belly digastric

Also controlled by the Facial Nerve

Taste in the anterior 2/3 of the tongue

Lacrimal, Submandibular, Sublingual gland, nasal, and palatine glands

Patient Demographics (Schonbeck & Gale, 2006)Patient Demographics (Schonbeck & Gale, 2006)

Most common cause of one-sided facial weakness for children.

Affects approximately one in every five thousand people worldwide and 40,000 americans each year.

It is seen more in area where AIDS or sarcoidosis (abnormal collections of inflammatory cells in multiple organs).

Seen more in adults with diabetes or in the last trimester of pregnancy.

No difference in numbers between males or females, right-side paralysis or left-side paralysis.

Most common cause of one-sided facial weakness for children.

Affects approximately one in every five thousand people worldwide and 40,000 americans each year.

It is seen more in area where AIDS or sarcoidosis (abnormal collections of inflammatory cells in multiple organs).

Seen more in adults with diabetes or in the last trimester of pregnancy.

No difference in numbers between males or females, right-side paralysis or left-side paralysis.

Evaluation (ahmed, 2005. ) Evaluation (ahmed, 2005. )

No readily identifiable cause

Herpes simplex I viral infections may play a role

Clinical characteristics of Bell’s palsy:

Peripheral dysfunction of CN VII Facial Nerve

Abrupt onset with maximal facial weakness occurring at 24-72 hours

No readily identifiable cause

Herpes simplex I viral infections may play a role

Clinical characteristics of Bell’s palsy:

Peripheral dysfunction of CN VII Facial Nerve

Abrupt onset with maximal facial weakness occurring at 24-72 hours

Evaluation COnt. (Ahmed, 2005. )Evaluation COnt. (Ahmed, 2005. )

Unilateral facial weakness that can be either complete or partial

Numbness or pain around the ear on the affected side

Reduced sensation of taste on the anterior 2/3 of tongue

Hypersensitivity to sounds

Usually presents with no history of trauma, local infection, tumor, or CNS disease

Unilateral facial weakness that can be either complete or partial

Numbness or pain around the ear on the affected side

Reduced sensation of taste on the anterior 2/3 of tongue

Hypersensitivity to sounds

Usually presents with no history of trauma, local infection, tumor, or CNS disease

Case Study EvaluationCase Study Evaluation

Patient is a 54 year-old female with Diabetes.

Patient woke up one day and could not feel the right side of her face and also could not move the right side of her face.

Patient complains of a dry eye because she no longer can sleep with it closed.

Patient also complains of drooling.

Patient is a 54 year-old female with Diabetes.

Patient woke up one day and could not feel the right side of her face and also could not move the right side of her face.

Patient complains of a dry eye because she no longer can sleep with it closed.

Patient also complains of drooling.

Examination (Ahmed, 2005.)Examination (Ahmed, 2005.)

It is important in the examination to rule out any other conditions

Bell’s palsy involves all branches of CN VII

If only one or two branches of CN VII are involved it is more indicative of a trauma or parotid gland tumor

Sometimes there are vesicular lesions on the skin of the ear and inside the ear caused by herpes zoster virus

Inner ear infections have also been associated with Bell’s palsy

Check for Bell phenomenon

Have the patient close their eyes. If the patient is unable to close the eyelid on the affected side but there will be normal upward eye movement.

It is important in the examination to rule out any other conditions

Bell’s palsy involves all branches of CN VII

If only one or two branches of CN VII are involved it is more indicative of a trauma or parotid gland tumor

Sometimes there are vesicular lesions on the skin of the ear and inside the ear caused by herpes zoster virus

Inner ear infections have also been associated with Bell’s palsy

Check for Bell phenomenon

Have the patient close their eyes. If the patient is unable to close the eyelid on the affected side but there will be normal upward eye movement.

Examination Cont.Examination Cont.

Inner ear infections have also been associated with Bell’s palsy

Check for Bell phenomenon

Have the patient close their eyes. If the patient is unable to close the eyelid on the affected side but there will be normal upward eye movement.

Inner ear infections have also been associated with Bell’s palsy

Check for Bell phenomenon

Have the patient close their eyes. If the patient is unable to close the eyelid on the affected side but there will be normal upward eye movement.

Examination Case StudyExamination Case Study

All nerves were checked with case study and only the facial nerve was affected.

Patient lacks all motor control in her face as well as most of the feeling.

She has no feeling on her right ear, cheek, mouth, nose, but has slight feeling on the medial 2/3rds of her eyelid up into her eyebrow.

All nerves were checked with case study and only the facial nerve was affected.

Patient lacks all motor control in her face as well as most of the feeling.

She has no feeling on her right ear, cheek, mouth, nose, but has slight feeling on the medial 2/3rds of her eyelid up into her eyebrow.

Diagnostic Testing (Ahmed, 2005.) Diagnostic Testing (Ahmed, 2005.)

If there is facial paresis, use the House-Brackmann facial nerve grading system. This is helpful to quantify the damage.

CT or MRI indications:

Lingering facial paresis after 1 month

Hearing loss

Multiple cranial nerve deficits

Signs of limb paresis or sensory loss

CT or MRI will rule out cerebellopontine angle tumor, stroke, multiple sclerosis, structural lesions, or temporal bone fractures.

Audiologic testing is warranted if hearing loss is suspected. This can also rule out acoustic neuroma.

Laboratory testing is indicated if there are signs of systemic involvement, such as fever, weight loss, rash, or progressive facial weakness without significant improvement over more than 4 weeks.

Lab tests:

CBC with differential: rules out lymphoreticular malignancy

Bell’s palsy is the initial manifestation of lymphoreticular malignancy

Blood glucose: used if diabetes mellitus is suspected

Serum antibodies against herpes zoster and B burgdorferi

B burgdorferi is the agent of Lyme disease, which could cause Bell’s palsy. Use only if Lyme disease is suspected

Serum calcium and angiotensin-converting enzyme levels: rules out sarcoidosis

Cerebrospinal fluid testing: used if infection or malignancy is suspect

Patients with Bell’s palsy already show elevated cell counts and protein levels.

Electrodiagnostic testing: used after 2 weeks of the condition to detect denervation and demonstrate nerve regeneration

If there is facial paresis, use the House-Brackmann facial nerve grading system. This is helpful to quantify the damage.

CT or MRI indications:

Lingering facial paresis after 1 month

Hearing loss

Multiple cranial nerve deficits

Signs of limb paresis or sensory loss

CT or MRI will rule out cerebellopontine angle tumor, stroke, multiple sclerosis, structural lesions, or temporal bone fractures.

Audiologic testing is warranted if hearing loss is suspected. This can also rule out acoustic neuroma.

Laboratory testing is indicated if there are signs of systemic involvement, such as fever, weight loss, rash, or progressive facial weakness without significant improvement over more than 4 weeks.

Lab tests:

CBC with differential: rules out lymphoreticular malignancy

Bell’s palsy is the initial manifestation of lymphoreticular malignancy

Blood glucose: used if diabetes mellitus is suspected

Serum antibodies against herpes zoster and B burgdorferi

B burgdorferi is the agent of Lyme disease, which could cause Bell’s palsy. Use only if Lyme disease is suspected

Serum calcium and angiotensin-converting enzyme levels: rules out sarcoidosis

Cerebrospinal fluid testing: used if infection or malignancy is suspect

Patients with Bell’s palsy already show elevated cell counts and protein levels.

Electrodiagnostic testing: used after 2 weeks of the condition to detect denervation and demonstrate nerve regeneration

Diagnostic Testing COnt. Diagnostic Testing COnt.

CT or MRI will rule out cerebellopontine angle tumor, stroke, multiple sclerosis, structural lesions, or temporal bone fractures.

Audiologic testing is warranted if hearing loss is suspected. This can also rule out acoustic neuroma.

Laboratory testing is indicated if there are signs of systemic involvement, such as fever, weight loss, rash, or progressive facial weakness without significant improvement over more than 4 weeks.

CT or MRI will rule out cerebellopontine angle tumor, stroke, multiple sclerosis, structural lesions, or temporal bone fractures.

Audiologic testing is warranted if hearing loss is suspected. This can also rule out acoustic neuroma.

Laboratory testing is indicated if there are signs of systemic involvement, such as fever, weight loss, rash, or progressive facial weakness without significant improvement over more than 4 weeks.

Lab Testing (Ahmed, 2005.)Lab Testing (Ahmed, 2005.)

CBC with differential: rules out lymphoreticular malignancy

Bell’s palsy is the initial manifestation of lymphoreticular malignancy

Blood glucose: used if diabetes mellitus is suspected

Serum antibodies against herpes zoster and B burgdorferi

B burgdorferi is the agent of Lyme disease, which could cause Bell’s palsy. Use only if Lyme disease is suspected

Serum calcium and angiotensin-converting enzyme levels: rules out sarcoidosis

Cerebrospinal fluid testing: used if infection or malignancy is suspect

Patients with Bell’s palsy already show elevated cell counts and protein levels.

Electrodiagnostic testing: used after 2 weeks of the condition to detect denervation and demonstrate nerve regeneration

CBC with differential: rules out lymphoreticular malignancy

Bell’s palsy is the initial manifestation of lymphoreticular malignancy

Blood glucose: used if diabetes mellitus is suspected

Serum antibodies against herpes zoster and B burgdorferi

B burgdorferi is the agent of Lyme disease, which could cause Bell’s palsy. Use only if Lyme disease is suspected

Serum calcium and angiotensin-converting enzyme levels: rules out sarcoidosis

Cerebrospinal fluid testing: used if infection or malignancy is suspect

Patients with Bell’s palsy already show elevated cell counts and protein levels.

Electrodiagnostic testing: used after 2 weeks of the condition to detect denervation and demonstrate nerve regeneration

Case StudyCase Study

Patient went to the doctor and the got a blood glucose testing as well as a CBC count.

The CBC count was normal but the blood glucose showed that she had diabetes which was a main factor for her Bell’s Palsy.

Patient went to the doctor and the got a blood glucose testing as well as a CBC count.

The CBC count was normal but the blood glucose showed that she had diabetes which was a main factor for her Bell’s Palsy.

Differential DiagnosisDifferential Diagnosis

Other causes of Facial Paralysis

Stroke

transient ischemic attack (TIA) or Mini stroke

Other causes of Facial Paralysis

Stroke

transient ischemic attack (TIA) or Mini stroke

Treatment/Rehab Treatment/Rehab

Biofeedback has been getting more popular for Bell’s Palsy due to the increased rate of patient’s being able to get movement in their face back faster. (Nakamura, 2003.)

Must do facial muscle exercises like opening the mouth, clenching the teeth, opening the eye, squinting the eye, smiling, blowing as hard as you can into your cheeks, etc.

Steroid and Antiviral medication (Prednisone and Acyclovir) if cause is Herpes.

Biofeedback has been getting more popular for Bell’s Palsy due to the increased rate of patient’s being able to get movement in their face back faster. (Nakamura, 2003.)

Must do facial muscle exercises like opening the mouth, clenching the teeth, opening the eye, squinting the eye, smiling, blowing as hard as you can into your cheeks, etc.

Steroid and Antiviral medication (Prednisone and Acyclovir) if cause is Herpes.

Case StudyCase Study

exercises talked about in previous slide

Resisted Motion Exercises

finger between lips

blowing up cheeks

exercises talked about in previous slide

Resisted Motion Exercises

finger between lips

blowing up cheeks

Outcome &STATS (Jabor & Gianoli G., 1996 )Outcome &STATS (Jabor & Gianoli G., 1996 )

84% show good recovery without any treatment.

16% suffer moderate to severe sequelae (condition that would be caused due to a previous disease)

More than 90% degeneration of the facial nerve carries a poor prognosis for recovery.

84% show good recovery without any treatment.

16% suffer moderate to severe sequelae (condition that would be caused due to a previous disease)

More than 90% degeneration of the facial nerve carries a poor prognosis for recovery.

take home pointstake home points

Bells Palsy is becoming more common each year

It is most common in people with diabetes and pregnant women

Biofeedback rehabilitation is becoming one of the best methods for regaining facial muscle strength.

It can happen to anyone !! Even stress can cause it.

Bells Palsy is becoming more common each year

It is most common in people with diabetes and pregnant women

Biofeedback rehabilitation is becoming one of the best methods for regaining facial muscle strength.

It can happen to anyone !! Even stress can cause it.

References References Ahmed, A. (2005). When is facial paralysis Bell palsy? Current diagnosis and treatment. Cleveland Clinic Journal of Medicine , 72 (5), 398-405.

Finsterer, Josef, Management of peripheral facial nerve palsy, Eur Arch Otorhinolaryngol. 2008 July; 265(7): 743–752.

Slavkin HC, The significance of a human smile: observations on Bell’s palsy. JADA (1999) 130:269–72.

Holland NJ, Weiner GM,Recent developments in Bell’s palsy, Br Med J 2004,329:553–557.

http://www.mayoclinic.com/health/bells-palsy/DS00168

http://clinicalcases.org/2004/09/stroke-or-bells-palsy-facial-droop.html

Gianoli, G. (1996). Management of Bell’s Palsy. Pubmed. Dept of Otolargy, Tulane University School of Medicine. Jul;148(7):279-83

Nakumara, K., et al. (2003.) Biofeedback Rehabilitation for Prevention of Synkinesis after Facial Palsy.

Taylor, (2012.), Reviewed by: Stöppler. Facial Nerve Problems and Bell’s Palsy. Medicinenet.com.

Ahmed, A. (2005). When is facial paralysis Bell palsy? Current diagnosis and treatment. Cleveland Clinic Journal of Medicine , 72 (5), 398-405.

Finsterer, Josef, Management of peripheral facial nerve palsy, Eur Arch Otorhinolaryngol. 2008 July; 265(7): 743–752.

Slavkin HC, The significance of a human smile: observations on Bell’s palsy. JADA (1999) 130:269–72.

Holland NJ, Weiner GM,Recent developments in Bell’s palsy, Br Med J 2004,329:553–557.

http://www.mayoclinic.com/health/bells-palsy/DS00168

http://clinicalcases.org/2004/09/stroke-or-bells-palsy-facial-droop.html

Gianoli, G. (1996). Management of Bell’s Palsy. Pubmed. Dept of Otolargy, Tulane University School of Medicine. Jul;148(7):279-83

Nakumara, K., et al. (2003.) Biofeedback Rehabilitation for Prevention of Synkinesis after Facial Palsy.

Taylor, (2012.), Reviewed by: Stöppler. Facial Nerve Problems and Bell’s Palsy. Medicinenet.com.