BELL’S PALSY (FACIAL NERVE PALSY)

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

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.

Bell's Palsy

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.
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