Bells Palsy

Marthin Tori
KSM Neurologi RSUD dr. Doris Sylvanus
P.Raya 2018
Introduction
• The condition is named for the
Scottish surgeon who first described
it in the 1800s, Sir Charles Bell

• In the 19th century he published his discovery that

the facial nerve innervates the facial muscles that
give facial expression.

• He further more reported that the trigeminal nerve

mainly is responsible for facial sensation and
described several cases of facial paralysis due to
trauma or infection
 Definition

Bell palsy is an idiopathic peripheral

nerve disorder involving the facial nerve
(cranial nerve VII) and manifesting as
acute, ipsilateral facial muscle
weakness with pain, abnormal taste,
and reduced tearing.

Patel D, Levin K. Bells Palsy :Clinical examintaion and Management. Cleavelnd Clinic Journal of Medicine. July
2015. Vol 82;7
 Epidemiology

• It affects 20–30 persons per 100 000 annually

• women who are pregnant and diabetics
higher risk
• Both genders tend to be affected equally
• The peak age for Bell’s palsy onset is during
the third and fourth decades of life
(between 20 and 40 years of age)

Cormier J. Bell”s Palsy : A common Cause of Facial Paralysis. Texas EMS Magazine . November/Desember 2012
Anatomy Facial Nerve
Mullen MT, Difereciating Facial Weakness Caused by Bell’s Palsy VS Acute Stroke. JEMS. May 2014
Periperal Facial Palsy
Etiology
The etiology of Bell's palsy is unknown but the
most possible pathomechamism are :

Vascular ischemia
Viral Infection
Autoimmune disease
Greco. A et al. Bell’s Palsy and Autoimmunity. Autoimmunity Reviews 12 (2012) 323-328
 Vascular Ischemia
possibly triggered by cold
temperature or
psychosomatically,

spasm of arterioles nourishing

the facial nerve

The suffocation of nutrients

would induce a secondary
ischemia and incite edema of
the nerve

Compression against the facial

canal and engender a facial
palsy.

Pham V, Young D, Makishima T. Bell's Palsy. Grand Rounds Presentation, Department of Otolaryngology The University
of Texas Medical Branch (UTMB Health). October 2012
Viral Infection
Latent herpes viruses (herpes simplex, herpes zoster) which has
been found postmortem in a collection of cranial nerve fibers
called the geniculate ganglion being reactivated

inflammation of the facial nerve

Reversible neurapraxia, and ultimately in wallerian

degeneration

Virus infection with herpes simplex type 1 or herpes

zoster may predominantly occur if the immune
system is simultaneously compromised

Herpes viruses have been detected by polymerase

chain reaction (PCR) within the facial nerve

Kes VB et al. Peripheral Facial Weakness (Bell’s Palsy). Acta Clin Croat 2013;52: 195-202
Immunological hypothesis

Greco et al.Bells Palsy and Autoimmunity. Autoimmunity reviews 12 (2012) 323-328

Pathophysiology

swelling of the facial nerve trunk in the narrow confines

of the facial canal leads to local compressive ischemia

further swelling and edema.

local interruption of blood supply to the facial nerve

and thus extension of the ischemic injury

Kes VB et al. Peripheral Facial Weakness (Bell’s Palsy). Acta Clin Croat 2013;52: 195-202
Diagnosis
History :
 Acute onset of unilateral upper and lower facial
paralysis (over a 48-h period), patient complain a
poor eyelid closure ,aching of the ear or mastoid,
Alteration of taste , Tingling or numbness of the
cheek/mouth and sometimes Blurred vision
 History of activity or job that had been done at
night, outside
 inquiry on exposure to various viruses (herpes,
chicken pox-varicella zoster, HIV, etc) and history
of stress and cold symptoms.
Physical Examination

Patel D er al. Bell Palsy : Clinical Examination and Managemnet. CCJM. 82: 7. July 2015
Signs and Symptoms
 Diagnosis Topis :
Kelainan Gangguan Gangguan Hiposekresi Hiposekresi
Letak Lesi
motorik pengecapan pendengaran saliva lakrimalis
Pons-meatus akustikus
+ + + tuli/hiperakusis + +
internus
Meatus akustikus internus- +
+ + + +
ganglion genikulatum Hiperakusis
Ganglion genikulatum-N. +
+ + + -
Stapedius Hiperakusis
N.stapedius-chorda tympani
+ + + + -

Chorda tympani + + - + -
Infra chorda tympani-sekitar
foramen stilomastoideus + - - - -
Facial Grading System
UGO FISCH
Position Score Persentage (%) Score
0, 30, 70, 100

Resting 20
wrinkle forehead 10
close eyes 30
smile 30
Whistle 10
Total

Level I : Normal (100 point) Penilaian persentase :

Level II : Mild paralysis ( 75 – 99 point),
Level III : Moderate paralysis (50 – 75 point) 0 % :Complete asymmetrical, no
Level IV : moderate – severe paralysis( 25 –
voluntary movement
50 point)
Level V : Severe Paralysis (1 – 25 point) 30 %: Symmetrical, poor
Level VI : total Paralysis (0 point) 70 %:Symmetrical, fair
100%:Symmetrical, normal
 Eye
Protection

Medication

Hyperbaric
oxygen
Management

Physiotherapy

Acupuncture

Surgery

Zhao Y et al. Advances in Diagnosis and Non-surgical Treatment of Bells pallsy.Journal of Otology 10
(2015) 7-12
Eye protection
 Facial paralysis can lead to eye closure failure,
which, without timely intervention, can result in
corneal ulceration, scarring and vision loss

 Intervention is based upon judgment on the

prognosis of facial nerve function as well as the
lagophthalmos

 Mild lagophthalmos : artificial tears, ointment,

humidifying cover, eyelid implant, botulinum
toxin or eyelid stitches
Medication

Antiviral
Steroid
Medication

 Oral steroids within 72 h of occurrence of Bell's palsy are strongly

recommended, while sole use of anti- viral drugs or in patients
with newly developed Bell's palsy is advised against (Baugh et
al., 2013)
 Steroids can not only improve prognosis in facial paralysis, but
also improve quality of life and sleep although they do not
provide pain relief
 Compared to steroids, prognosis was worse in patients
receiving anti-viral agents.
 while antivirals might have some effects in treating peripheral
facial paralysis, the effects were small.
 Medication

Tiemstra J, Khatkhate N. Bell’s Palsy: Diagnosis and Management. American Family Physician. Volume 76, Number 7.
Medication

America Academy of Neurology 2012

Source:
http://www.palmettohealth.com/pharmacy/Methylpred%20Shortage%2
0Info.pdf
Physiotherapy

Electric
Biofeedback Mime Play
Stimulation
 FACIAL EXERCISES

Sit relaxed in front of a Gently raise eyebrows, Draw your eyebrows

you can help the movement
Wrinkle up your nose
mirror with your fingers together, frown

Take a deep breath through Gently try and move Try and keep the movement the You can use your fingers to
your nose, try and flare nostrils corners of mouth outwards same on each side of your face help. Once in position take
your fingers away and see
if you can hold that smile

Lift one corner of the m outh …. then the other

EXERCISES TO HELP CLOSE THE EYE

Look Down Gently place back of index With opposite hand gently stretch eyebrow up …. working along the
finger on eyelid, to keep brow line. This will help relax the eyelid and stop it from becoming stiff.
the eye closed

Now try and gently press Narrow eyes as if

the eye lids together looking into the sun

The Bell’s Palsy Association

www.bellspalsy.org.uk
This leaflet reproduced with the kind perm ission of L. Clapham, Superintendant Physiotherapist, Wessex Neurological Centr e, Southampton General Hospital
Surgery

Surgical options for Bell palsy include the following:

 Facial nerve decompression

 Subocularis oculi fat (SOOF) lift

 Implantable devices (eg, gold weights) placed

into the eyelid

 Tarsorrhaphy

 Transposition of the temporalis muscle

 Facial nerve grafting

 Direct brow lift

Almeida JR et al. Management of bell Palsy : Clinical Practice Guideline. CMAJ 2014
 Prognosis

 Generally very good.

 at least 70–90% of patients improve without treatment, and 95%

achieve complete functional recovery with corticosteroid
treatment.

 With or without treatment, most individuals begin to get better

within 2 weeks after the initial onset of symptoms and most
recover completely, returning to normal function within 3 to 6
months

 In a few cases, the symptoms may never completely disappear

 In rare cases, the disorder may recur, either on the same or the
opposite side of the face

Kanerva M. Peripheral Facial Palsy. Department of Otorhinolaryngology University of Helsinki Finland.

2008
KOMPLIKASI

Crocodile tear
phenomenon

Kontraktur Synkinesis

Hemifacial
spasm