Bell's Palsy_BNS 3rd year.CMC.edu...pptx

CENTRAL NERVOUS SYSTEM

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2. General Objective At the end of the session, BNS 3 rd year students will be able to explain about Bell’s Palsy. 2

3. Specific objectives At the end of the session, BNS 3 rd year students will be able to: introduce bell’s palsy. define bell’s palsy. state incidence of bell’s palsy. explain the etiology of bell’s palsy. describe the pathophysiology of bell’s palsy. state the clinical manifestations of bell’s palsy. state the diagnostic investigation of bell’s palsy. explain management of bell’s palsy. 3

4. contd .. explain nursing management of bell’s palsy. state the complications of bell’s palsy. describe the prognosis of bell’s palsy. 4

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6. Anatomy facial nerve The facial nerve is the seventh cranial nerve (CN VII). It arises from the brain stem and extends posteriorly to the abducents nerve and anteriorly to the vestibulocochlear nerve. 6

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8. The facial nerve has five branches that perform distinct motor functions: Frontal (temporal):  Controls your forehead muscles. Zygomatic:  Helps you close your eyes. Buccal:  Allows you to move your nose, blink and raise your upper lip and corners of your mouth to make a smile . Marginal mandibular:  Draws your lower lip down (like a frown) and travels through your middle ear to help you respond to loud noises. Cervical:  Controls movement in your chin and lower corners of your mouth . 8

9. Bell’s Palsy Prepared by : Samikshya Banjara BNS 3 rd year 14 th batch Chitwan Medical College 9

10. Introduction Bell’s Palsy (facial paralysis) is due to unilateral inflammation of the seventh cranial nerve (facial nerve) , which results in weakness or paralysis of the facial muscles on the affected side . Bell’s palsy is the most common acute mononeuropathy (disease involving only one nerve) and is the most common cause of acute facial nerve paralysis. 10

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12. contd .. Right side is affected most (65%) commonly. Sir Charles Bell of England first described acute paralysis of cranial nerve VII(Facial Nerve)in 1821 A.D. Because of Bell’s interest in this nerve disorder, the disease has been called Facial paralysis or Bell’s palsy. 12

13. Definition Bell’s palsy is defined as an idiopathic unilateral facial nerve paralysis, usually self limiting. The hallmark of this condition is a rapid onset of partial or complete palsy that often occurs overnight. In rare cases(1 %), it can occur bilaterally resulting in total facial paralysis. 13

14. Incidence Bell’s palsy affects about 40,000 people in the United States every year. It affects approximately 1 person in 65 during a lifetime. Bell’s palsy is more commonly seen in young adults, and persons of Japanese descent have a slightly higher incidence of the condition . It is also considered to be four times more likely to occur in diabetics than the general population . 14

15. contd .. Bell’s palsy is the most common cause of facial paralysis worldwide and one of the most common neurological disorders involving a cranial nerve. Incidence of Bell’s palsy in males and females, as well as in various races, is approximately the same . And recovery also is equal. ( Rubinowicz , R ). The severity of the condition (e.g., mild, severe), and the rate of recovery also is equal. Familial inheritance has been found in 4-14% of cases . 15

16. Risk factors It can affect anyone at any age and sex, however commonly affect Pregnant women and people with diabetes mellitus. Pregnancy (Potentially due to hypercoagulability, increased blood pressure and fluid load, viral infection and suppressed immunity) Most patient experience a viral prodrome (e.g. upper respiratory infection 1 to 2 weeks before onset of symptoms). Family history of the condition. 16

17. Etiology Unknown cause (Idiopathic ). Evidence shows that reactivated herpes simplex virus (HSV) may be involved in some cases. Reactivation of the HSV causes inflammation, edema, ischemia, and eventual demyelination of the facial nerve, causing pain and alterations in motor and sensory function. May be caused by a viral infection: Viral meningitis Herpes simplex 17

18. c ontd … Secondary to autoimmune reaction. Hereditary (4% cases ). Tumor: Tumor compress the facial nerve causing facial palsy but more commonly the facial palsy is seen in surgical removal of tumor. Chronic ear infections. High blood pressure, Diabetes . Sarcoidosis . HIV, which damages the immune system. 18

19. Pathophysiology Inflammation of the facial nerve The inflamed edematous nerve becomes compressed to the point of damage, or its nutrient vessel is occluded Producing ischemic necrosis of the nerve Blocking the transmission of neural signals or damaging the nerve 19

20. contd.. There is distortion of the face from paralysis of the facial muscles; increased lacrimation (tearing ); and painful sensation in the face, behind the ear in the eye 20

21. Classification 1. Central bell’s palsy/ facial palsy : It is characterized by paralysis or paresis of the lower half of one side of the face. It usually results from damage to upper motor neurons of the facial nerve. Preservation of forehead and brow movements. Loss of nasolabial folds and drooping of lower lip. 21

22. c ontd … 2. Peripheral bell’s palsy/ facial palsy: It is characterized by paralysis or paresis of facial nerve on one side of the face (unilateral facial paralysis with forehead involvement) Inability to close eyes and drooping of eyes. Loss of forehead and brow movements. Loss of naso labial folds and drooping of lower lip. 22

23. Clinical Features Sign and symptoms varies on the area affected. Appearance and range of movement Functional effects Somatic effects 23

24. c ontd … Typical symptoms : Upward movement of the eyeball on closing the eye (Bell’s phenomena) Drooping of the mouth Flattening of the nasolabial fold Widening of the palpebral fissure A slight lag in closing the eye. Eating may be difficult. 24

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26. Flattening of the nasolabial fold

27. c ontd … Appearance and Range of Movement Inability to close the eye. Inability to move the lips. At rest, the affected side of the face may droop. Facial synkinesis is seen (It is the abnormal facial movements that occurs during spontaneous) movements. Ectropion . 27

28. Synkinesis

29. c ontd.. Functional Effects Difficult to eat and drink as there is lack of lip seal making it difficult to keep fluid and food in the mouth. Reduced clarity of speech as it require lip seal like b, p, m,v , f. Dryness of the affected eye. 29

30. c ontd … Somatic Effects : As facial nerve supplies the lacrimal gland of eye, salivary gland, muscle of stirrup (stapes) bone in the middle ear and 2/3rd part of tongue. Lack of tear causing dryness and risk of corneal ulceration ( petrosal nerve is affected which control moisture in eye ). Zygomatic branch of facial nerve damage lead to loss of closure of eye or blinking of eye. Hyperacusis (sensitive to sudden loud noises ). Alteration in taste sensation. 30

31. contd.. Others symptoms that may occur : Dry eye or mouth. Headache. Twitching in face . Painful sensations in the face, behind the ear, and in the eye. A painful weakness of one side of the face. This weakness may develop within just hours, or overnight but it usually appears progressively over several days . A cold is starting before the bell’s palsy symptoms. 31

32. Grading developed by House and Brackmann categorizes Bell palsy on a scale of I to VI. 1. Grade I is normal facial function. 2. Grade II is mild dysfunction where characteristics include the following:- Slight weakness is noted on close inspection. Slight synkinesis may be present (abnormal synchchronization of facial movement) Normal symmetry and tone are noted at rest. 32

33. contd .. Forehead motion is moderate to good. Complete eye closure is achieved with minimal effort. Slight mouth asymmetry is noted. 33

34. c ontd … 3. Grade III is moderate dysfunction which include the following characteristics:- An obvious, but not disfiguring, difference is noted between the two sides A noticeable, but not severe, synkinesis, contracture, or hemifacial spasm is present Normal symmetry and tone are noted at rest. Forehead movement is slight to moderate Complete eye closure is achieved with effort A slightly weak mouth movement is noted with maximal effort. 34

35. c ontd …. 4.Grade IV is moderately severe dysfunction sign include the following:- An obvious weakness and / or disfiguring asymmetry is noted. Symmetry and tone are normal at rest. No forehead motion is observed. Eye closure incomplete. An asymmetrical mouth is noted with maximal effort. 35

36. c ontd ….. 5. Grade V is severe dysfunction where the characteristics are:- Asymmetry is noted at rest. No forehead motion is observed. Eye closure is incomplete. Mouth movement is only slight. 6. Grade VI is total paralysis and the characteristics are following:- Gross asymmetry No movement. 36

37. Grades I and II are consider goods outcomes. Grades III and IV represent moderate dis function. Grade V and VI describe poor results. Grade VI is defined as complete facial paralysis. 37

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39. Diagnostic Investigation Bell’s palsy can be diagnosed just by taking a health history and doing a complete physical examination History taking :- To determine previous illness, onset of paralysis. Physical examination :- Evaluation of 7 th Cranial Nerve and Corneal sensation along with ontological and ocular examinations. Blood test:- for sugars and kidney function. CT scan of the head. 39

40. contd .. Magnetic resonance imaging (MRI) of the head. Electromyography(EMG ). Lumbar Puncture for CSF analysis. Nerve conduction velocities to evaluate a nerve function . A nerve conduction velocity (NCV) test measures how fast an electrical impulse moves through the nerve. NCV can identify nerve damage. This test is also called a nerve conduction study. During the test, the nerve is stimulated, often with electrode patches on the skin. 40

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42. Management The objectives of the treatment is to maintain the muscle tone of the face and to prevent or minimize denervation. Drug Therapy. Surgery. Complementary therapy. Physiotherapy. Supportive therapy. 42

43. Planning Overall goals of Bell’s palsy management are: Be pain free or have pain control Maintain adequate nutritional status Maintain appropriate oral hygiene Not experience injury to the eye Return to normal or previous perception of body image

44. contd .. 1 . Steroids Corticosteroid such as prednisone,7 to 10 days course of corticosteroid (starting with 60mg/day) in the acute stage ( with in 5 to 7 days). Significantly improves recovery at 6 months and are thus recommended. If steroid is used within 3 days of onset then there is >14% recovery chances . 2.Antiviral Antiviral(such as acyclovir) are ineffective in improving recovering from bell’s palsy beyond steroids alone Combination of prednisone and acyclovir (1g 3times a day for a week ) 44

45. contd .. Surgery Although most patients recover with conservative treatment . Surgical exploration of the facial nerve may be indicated patients who are suspected of having a tumor for surgical decompression of the facial nerve and for surgical treatment of a paralyzed face. Surgery may be able to improve outcomes in facial nerve palsy that has not recovered. 45

46. c ontd … Surgery is recommended in patients with complete Bell’s Palsy with no response to medical therapy and with 90% axonal degeneration. Surgery includes: plastic surgery includes facial reanimation (eyebrow lifting, facial implant, nerve grafting) surgery that makes face look more even and may restore facial movement. 46

47. c ontd … Smile surgery or smile reconstruction is a surgical procedure that restores the smile for people with facial nerve paralysis. 47

48. contd .. Complementary therapy Acupuncture Physiotherapy Maintain muscle tone, stimulate the facial nerve Prevent permanent contractures Reduce pain 48

49. contd .. Supportive therapy Transcutaneous electrical stimulation can be effective treatment strategy (Muscles atrophy) 49

50. contd.. Facial pain is controlled with analgesic agents. Heat may be applied to the involved side of the face promote comfort and blood flow through the muscles. 50

51. Nursing Management 51

52. Assessment History Taking: To determine previous illness, onset of paralysis, family history. History of any respiratory infection, meningitis etc. History of any autoimmune diseases. 52

53. c ontd.. 2. Physical Examination: Motor components of facial nerve of assessing patient smile ability to whistle, purse lips, wrinkle forehead and close eyes. Observe for facial asymmetry. Observe patient ability to handle secretions, food, fluids, : observe for drooling. Assess patient ability to blink and speak clearly. Assess effects of altered appearance on body image. 53

54. Nursing diagnosis Acute pain related to inflammation of seventh cranial nerve. Imbalanced nutrition: less than body requirement related to inability to chew secondary muscles weakness. Impaired oral hygiene related to unwillingness to practice oral hygiene measures secondary to potential for initiation of pain . 54

55. contd .. Disturbed body image related to change in facial appearance secondary to facial muscles weakness. Disturbed sensory perception related to dysfunction of facial nerve. Risk for injury (Corneal abrasion) related to inability to blink. Impaired verbal communication related to inability to voluntarily move mouth . Social isolation related to impaired facial structure and difficulty in communication. 55

56. Nursing Intervention 56

57. Relieving of pain Mild analgesic can relieve pain Hot water pack to reduce the discomfort for herpes lesion, and circulation and pain Face should be protected from cold and drafts because trigeminal hyperesthesia (extreme sensitivity to touch or pain) may accompany the syndrome. 57

58. contd .. Patient should be taught to chew on the unaffected side of the mouth to avoid trapping food and to enjoy the taste of food. Oral hygiene must be carried out after each meal to prevent the development of parotitis, carries and dental disease from accumulated residual food . A facial sling may be helpful to support affected muscles, improve lip alignment and facilitate eating Avoid vigorous massage, but gentle upward massage has psychologic benefits . When function begins to return, active facial exercise are performed several times a day . 58

59. Maintain nutrition pattern Assess nutrition pattern. Patient should be taught to chew on unaffected side to avoid trapping food and to enjoy taste of food. Oral hygiene must be carried out to improve appetite. Provide small food but frequently . Monitor daily weight of patient. Advised the patient to avoid foods that are hard, stringy, chewy, or those that include pips, skins, shells, or husks 59

60. Enhancing body image and promote social interaction Encourage the patient to express feelings related to body image disturbance. Encourage the patient to use mirror as means to obtain feedback about actual versus perceived appearance. Provide psychological support . Introduce them with social groups of bell’s palsy for enhancing their self esteem and making them realize they are not only the sufferer. 60

61. Protecting eye injury Dark glasses may be worn for protection. Artificial tears (methylcellulose) should be installed frequently during the day to prevent drying of the cornea. Ointment and an eye shield can be used at night to retain moister. Taping the lids closed at night. Advised the patient to report eye pain immediately. 61

62. To promote verbal communication Advice the patient for physiotherapy that helps to promote verbal functions. If the patient have problem in verbal communication, then non verbal technique can be used. Don’t bias the patient and encourage them for verbal communication according to their limitation. 62

63. Promoting home and community based care 63

64. Teaching patients self care Prevent from dust and foreign particles. To prevent injury, the eye should covered with a protective shield at night The eye patch may be abrade the cornea however, because there is some difficulty in keeping the partially paralyzed eye lies closed . Tell the patient to protect the face from cold and drafts because trigeminal hyperesthesia (extreme sensitivity to pain or touch) may occur . 64

65. contd .. The application of eye ointment at bed time caused the eye lids to adhere to another and remain closed during sleep . The patient can be taught to close the paralyzed eye lids manually before going to sleep. Warp around sun glasses or goggles may be worn to decrease normal evaporation from the eye . 65

66. contd .. The patient can be taught to close the paralyzed eye lids manually before going to sleep. Warp around sun glasses or goggles may be worn to decrease normal evaporation from the eye . Massaging the face several times daily, using a gentle upward motion to maintain muscles tone. Facial exercise, such as wrinkling the forehead, blowing out of the cheeks, the whistling may be performed with the aid of a mirror in an effort to prevent muscle atrophy . 66

67. Prognosis Most cases go away completely with in a few weeks to month. Even without any treatment, bells palsy tends to carry good prognosis. Long term change in taste. Spasms of muscles or eye lids Weakness that remains in facial muscles Prognosis of bells palsy is generally favorable with excellent recovery in up to 70% cases . 67

68. Complications Excess drying of the eye surface, leading to eye ulcers or infections. Malnutrition. Dehydration. Mucous membrane trauma. Corneal abrasion. Muscles stretching. Facial spasm and contracture.

69. References Basavanthapa , B.T (2009).Medical Surgical Nursing(2 nd edition).Jaypee Brothers, New Delhi Black, J.M. & Hawks, J.H. (2014). Medical Surgical Nursing Volume 2. (8 th ed.). South Asian Edition. Daniels, R., Nosek , L. & Nicoll , L. (2007). Contemporary Medical-Surgical Nursing. (1 st ed.). India Edition. Hinkle, J.K. & Cheever, K.H. (2014). Brunner & Suddarth’s Textbook of Medical Surgical nursing Volume 2. (13 th ed.). South Asian Edition. (2050). 69

70. contd.. Panwar, P.K. (2012). Medical Surgical Nursing (1 st edition). Aitbas publishers, India Net References https ://www.hopkinsmedicine.org/health/conditions-and-diseases/bells-palsy 70

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