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1. Bell’s Palsy: 13-05-2024 1

2. 13-05-2024 2 BELLS PALSY

3. Motor nucleus of VII CN is antero lateral to VI CN nucleus Parasympathetic fibres Red line motor fibers Visceral afferent fibres 13-05-2024 3 BELLS PALSY

4. Submandibular ganglion Submandibular gland 4

5. Bell’s Palsy Defined It is an idiopathic paralysis of the facial nerve of sudden onset. Unilateral lower motor neuron paralysis of sudden onset,not related to any other disease elsewhere in the body. 13-05-2024 5 BELLS PALSY

6. Who is Bell ? Charles Bell known for his studies on the nervous system and the brain. In the 19 th century discovered that lesions of the 7 th cranial nerve causes facial paralysis. 13-05-2024 6 BELLS PALSY

7. Facial Nerve Each nerve controls: Eye blinking and closing Facial expressions Smiling and frowning Tear glands Saliva glands Muscle of small bone in middle of ear called the stapes Taste sensations 13-05-2024 7

8. Cause Unknown cause 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.   13-05-2024 8 BELLS PALSY

9. May be caused by a viral infection Viral meningitis Herpes simplex Headaches Chronic ear infections High blood pressure Diabetes Sarcoidosis Tumors Lyme disease trauma 13-05-2024 9 BELLS PALSY

10. Because it's swollen, the nerve gets compressed as it passes through a small hole at the base of the skull, which causes the symptoms of Bell's palsy. Bell's palsy can affect people of all ages, but it is most common in adults. People with diabetes and pregnant women are more likely to develop Bell's palsy. 13-05-2024 10 BELLS PALSY

11. Examination Differentiate between upper and lower motor neurone lesion UML: frontalis is spared allowing normal furrowing of brow and eye blinking LML: all muscles of facial expression are affected 13-05-2024 11 BELLS PALSY

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13. Evaluation Careful history – timing Associated symptoms recurrent Physical exam CT/MRI Electrophysiology 13 13-05-2024 BELLS PALSY

14. S/S Varies from person to person Comes on suddenly Mild to total paralysis Weakness, twitching on one of both sides of the face Facial and eyelid droop Drooling Dryness of eye or mouth Impairment of taste Excessive tearing of eye 13-05-2024 14 BELLS PALSY

15. Pain behind the ear may precede the paralysis by a day or two . Impairement of taste is present to some degree in all cases –rarely beyond second week of paralysis. Hyperacusis or distortion of sound in ipsilateral ear ---paralysis of stapedius muscle. 13-05-2024 15 BELLS PALSY

16. Patient feels stiffness of face pulled to one side. Ipsilateral restriction of eye closure, difficulty with eating ,fine facial movements. Disturbance of taste – chorda tympani fibres Hyperacusis —fibers to stapedius 13-05-2024 16 BELLS PALSY

17. BELL’S PHENOMENON Normally on closing the eye ,the eyeball moves upwards and inwards. This is on the affected side due to ineffective closure of the eyelids. 13-05-2024 17 BELLS PALSY

18. Clinically Corner of mouth droops Skin folds effaces Forehead is unfurrowed Eyelids will not close Eye on the paralysed side rolls upward –BELL’S PHENOMENON Lower lid sags and falls away from conjunctiva Tearing. Saliva may dribble from the corner of the mouth Heaviness or numbeness of the face 13-05-2024 18 BELLS PALSY

19. House - Brackmann grading system Grade I - Normal Grade II - Mild dysfunction, slight weakness on close inspection, normal symmetry at rest Grade III - Moderate dysfunction, obvious but not disfiguring difference between sides, eye can be completely closed with effort Grade IV - Moderately severe, normal tone at rest, obvious weakness or asymmetry with movement, incomplete closure of eye Grade V - Severe dysfunction, only barely perceptible motion, asymmetry at rest Grade VI - No movement 13-05-2024 19 BELLS PALSY

20. Diagnosed There are no specific lab tests to confirm diagnosis Will exam for upper and lower facial weakness Electromyography Confirm presence of damage and determine severity MRI and CT causes of pressure on nerve 13-05-2024 20 BELLS PALSY

21. Differential diagnosis Stroke Herpes zooster virus Lyme disease 13-05-2024 BELLS PALSY 21

22. Prognosis 80% patients recover within a few weeks.2-12 weeks. 10%--permanent disfigurement.long term sequelae . 8%--recurrence Best clinical guide to progress is the severity of the palsy during the first few days after presentation. Recovery of taste precedes motor function. 13-05-2024 22 BELLS PALSY

23. If recovery of taste occurs in first week – good prognostic sign. Early recovery of motor function in the first 5-7 days— most favourable prognosis. Recurrence is due to reactivation of virus,pregnancy . Interval between periods is not predictable. 13-05-2024 23 BELLS PALSY

24. Treatment Controversial Symptomatic Protection of eye during the sleep -patch Massage of the weakened muscles Lubricating eye drops Prednisolone 60-80 mg/day in divided doses intial 4-5 days,then taper over next 7-10 days. Decreases the possibility of permanent paralysis From swelling of facial nerve in facial canal. Decreases the severe pain. 13-05-2024 24 BELLS PALSY

25. Medical treatment A cyclovir 400 mg 5 times/day F amciclovir and valacyclovir 500 mg bid 13-05-2024 25 BELLS PALSY

26. Surgical treatment Facial nerve decompression Indication Completely paralysis Appropriate time for surgery is 2-3 weeks after paralysis. 13-05-2024 26 BELLS PALSY

27. Electrophysiology Treatment plan based on 16% of patients who do not fully recover Several tests used for prognosis Measure amounts of neural degeneration occurred distal to injury by measuring muscle response to electrical stimulus Able to differentiate nerve fibers undergoing Wallerian degeneration. 27 13-05-2024 BELLS PALSY

28. Temporal bone fractures Signs bleeding from the external canal hemotympanum step-deformity of the osseous canal conductive hearing loss (longitudinal fracture) sensorineural hearing loss (transverse fracture) CSF otorrhea facial nerve involvement (20% of longitudinal fractures and 50% of transverse fractures) 13-05-2024 28 BELLS PALSY

29. Longitudinal VS Transverse Type of injury Longitudinal Transverse Incidence 70-90% 10-20% Site of injury Temporal , Parietal area Occipital , Frontal area 13-05-2024 29 BELLS PALSY

30. Sequelae Long delay in the onset of recovery—3months Regeneration of nerve –2 years Incomplete Crocodile tears Facial spasms 13-05-2024 30 BELLS PALSY