BELL’S PALSY (FACIAL NERVE PALSY)

Bell’s Palsy is a disorder characterized by disruption of the motor branch of the facial nerve (CN vii) or paralysis of one side the face in absence of stroke

Sir Charles Bell, Scottish Surgeon, first described in early 1800’s based on trauma to facial nerves

Table of Contents

Prevalence

It occurs at any age
But most often seen in adults between 20 and 60 years
The incidence is equal in men and women

Prognosis

80% of clients recover completely with in a few weeks to a few months
3-4% recover without any treatment
15% recover but have some permanent facial paralysis. These clients are usually older with other conditions like DM

Causes

The exact cause is unknown but can be triggered by bacterial or viral infections like :

Herpes simplex
HIV
Sarcoidosis. growth of tiny collections of inflammatory cells in different parts of the body
Herpes zoster
Epstein-Ban
Lyme disease (bacterial infection caused by infected ticks)

It is also believed to occur due to localized inflammatory reaction of the facial nerve at the stylomastoid foramina.

Demyelination of the nerve can trigger bell’s palsy.

Pathophysiology

The facial nerve has motor nerves that innervate the muscles of expression on the face and sensory that supplies the tongue. Disruption of the nerve lead to rapid weakening or paralysis of the facial muscles on one side creating a mask like appearance (angry face)
Paralysis develops in 24-36 hours and eye of the affected side tears constantly.
The condition accompany outbreak of herpes vesicle around the ear.

Signs and symptoms of Bell’s palsy

Dribbling/drooling of saliva from the angle of the mouth affected and dropping of the face.
Difficult in closing the affected eye
Food collects between teeth and cheeks in the affected side
Nasal labial fold is effaced on the affected side when the patient is asked to show his/her teeth.
Absence of furrows on the affected side (like smooth forehead) when the patient looks up while the healthy side they
are present.
The patient fails to whistle.
Bell’s sign (failure of the eye to close and roll up ward on the affected side
Mouth deviates to normal side
Inability to perform facial expression like smiling.
Unilateral loss of taste
Pain behind the ear before paralysis with fever, tinnitus or hearing difficulty
Facial weakness
Muscle twitches
Dry eyes and mouth
Headaches
Sensitivity to sound

Differential Diagnosis

Lyme disease
Otitis media
Tumor
Multiple sclerosis

Complications of Bell’s Palsy

Malnutrition
Psychological withdrawal
Dehydration
Muscle stretching and facial spasms
Synkinesis -involuntary contraction of certain muscles when you’re trying to move others.
Excessive dryness in eyes which can lead to eye infections and blindness.
Psychological withdrawal changes in appearance, malnutrition or dehydration, mucous membrane trauma, corneal abrasion, muscle stretching, and facial spasms and contractures.

Investigations

Diagnosis made on basis of symptoms in the absence of other causes of paralysis such as stroke.
No definitive test
Electromyography (EMG) may determine nerve excitability or absence
MRI or CT scan to check the nerves in the face

Management of Bell’s Palsy

There is no specific treatment of the condition and hospitalization is not required;

MEDICAL MANAGEMENT

Corticosteroids- drug of choice
Prednisone may be started immediately!
Best if initiated before paralysis is complete
Taper off over 2 weeks(tapering is the process of stopping all opioids or reducing opioids quickly over a few days or weeks, decreasing the dose by 25% to 50% to 75% to 100%)
Decrease edema and pain
Analgesics e.g. ibruprofen may be needed for pain
Antivirals : Acyclovir (Zovirax) and Famvir because HSV is implicated in 70% of cases.
ABCs

NURSING CARE;

Warm moist sponge to relieve pain
Pad the dry eye
Nutrition
Physiotherapy and facial massage to stimulate facial muscles
Speech therapy
Alternative medicine ie massage, tai chi , yoga, pet therapy ,meditation
Joining support groups
If patient has corticosteroid therapy, aware of side effect like gastrointestinal distress and fluid retention.
If patient has diabetes condition, corticosteroid must be use carefully and monitor blood glucose
To reduce the pain, compress with warm compress on paralyzed face, but it should not burn the skin.
Use face strap to symmetrize the lip
Use of artificial tears
Ask patient to stay in warm circumstance, avoid dust and wind, and close the eye with dangerous exposure
To avoid complication in swallowing like aspiration and body weight decrease, ask patient to sit upright while he/she eats, chewing in non-paralyzed face side, chewing with small portion, consume balance nutrition foods, and avoid solid foods
Give patient privacy while patient has meal time, so the patient will not feel embarrassed
Perform mouth care and be careful since foods remain between lip and gingiva.
Give psychological support. Ensure the patient that the recovery needs 1-8 weeks
To maintain the muscle tonus, massage patient’s face with upward direction for 5-10 minutes, ask the patient to massage his face by his/her self.
If he/she is ready to do active exercise, ask the patient to smile in front of mirror.
Suggest the patient to close his/her eye with eye protector, especially if the patient is to go out.
Advice patient to close eyelids periodically and gently.