BELLS PALSY

• DEFINITIONAcute onset of non suppurative inflammation of the facial nerve above the stylomastoidforamen,producing a unilateral LMN FACIAL PALSY

• Incidence is 23/1,00,000Affects men and women equally , all ages ,all times of the year.Increased occurrence in the elderly diabetics, hypertensives than in the common people.Increased incidence in women during the third trimester of pregnancy 2 weeks preceding delivery ,first two weeks postpartum.

Etiology of Acute peripheral facial palsy

• Common-HSV type 1,varicella zoster virus

• Less common infection-Otitis media,Lymesdisease,EBV,CMV,Mumps,HHV 6,Intranasal influenza vaccine,Mycoplasma

• Other less common conditions-Trauma,Tumor,Hypertension,Guillain-Barresyndrome,Sarcoidosis,Melkerson rosenthalsyndrome,Ribavirin,Interferone

• Patho physiologyHSV I DNA in the endoneural fluid

• due to reactivation of the virus in the geniuclate ganglion.

• Onset of bell’s palsy is acute.½ of the cases attain maximum paralysis in 48 hours.All cases are clinically prominent by 5 days

• Pain behind the ear may precede the paralysis by a day or two .Impairement of taste is present to some degree in all cases –.(chorda tympani)Hyperacusis or distortion of sound in ipsilateral ear ---paralysis of stapedius muscle

• Paralysis is partial in 30%,complete in 70%cases.Jaw jerk is normalCorneal reflex is absentThese differentiate it from UMN palsy

• UMN TYPE LMN TYPE

• Upper face escapes total face involved

• Bells phenomenon-A Present

• Taste sensation presreved may be lost

• Corneal reflex-N Lost

• Plantar response-extnsr Flexor

• BELL’S PHENOMENONNormally on closing the eye ,the eyeball moves upwards and inwards.This is obvious on the affected side due to ineffective closure of the eyelids

• Clinically

• Corner of mouth droops

• Forehead is unfurrowed

• Eyelids will not close

• Eye on the paralysed side rolls upward –BELL’S PHENOMENON

• Wide palpebral fissure

• Watering from the eye or epiphora

• Food collects between the teeth and lips

• Saliva may dribble from the corner of the mouth

• Heaviness or numbeness of the face

• Sensory loss rarely demonstratble

• Loss of nasolabial fold

Investigations

• Enhancement of the facial nerve on gadolinium enhanced MRI

• Increased lymphocytes ,mononuclear cells in CSF.

Shirmer test

• ESR

• Blood glucose levels

• Prognosis85% patients recover within a few weeks.2-12 weeks.10%-mild facial weakness as a sequele.5%-are left with permanent severe facial weaknessBest clinical guide to progress is the severity of the palsy during the first few days after presentation.Recovery of taste precedes motor function

• 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

• TreatmentControversialSymptomatic1.Protection of eye during the sleep patch2.Massage of the weakened muscles 3.Lubricating eye drops4.Prednisolone 1mg/kg/day for 1 wk,followed by a 1wk taper.Decreases the possibility of permanent paralysisFrom swelling of facial nerve in facial canal.Decreases the severe pain

• 5.NSAIDS may be given for releif of pain and inflammation

• 6.Proper mouth wash is advised after each meal

• 7.Facial exercise is advised or consult physiotherapist

• 8.Galvanic current stimulation of paralysedmuscle may be of some help

• 9.If not improved at all within 6 wks-surgical decompression may be done at the stylomastiod foramen

• 10.Parenteral vitamin B1,B6 and B12 may be given; oral or parenteral methylcobalaminemay be of some help

• 11.Recently acyclovir or valanciclovir is tried, although the evidence for giving antivirals is poor.

• Complications1.Exposure keratitis

2.Hemifacial spasm 3.Facial contracture

4.Jaw winking

5.social embarrassment

Bad Prognostic Factors

1.Complete palsy at the beginning

2.Associated comorbidities

3.Hyperacusis or loss of taste sensation

4.Severe axonal degeneration on elecrophysiological study(EMG) after 10 days

• MELKERSSEN ROSENTHAL SYNDROME1.RECURRENT FACIAL PARLAYSIS2.LABIAL EDEMA3.FURROWING OF TONGUE

• Ramsay Hunt syndrome- Reactivation of dormant herpes zoster in the geniculateganglion

1.c/f –vesicles around the external ear canal,pinna,soft palate-sensorineuralHL,Vertigo due to involvement of VIII th nerve along with facial palsy

• D.DIAGNOSISLyme diseaseRamsay hunt syndromeSarcoidosisGuillainbarre syndromeLeprosyDiabetesAmyloidosisMelkersonrosenthal syndromeAcoustic neuromaMutiple sclerosisMiddle ear infections

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