BELL'S PALSY

dr. Wahyu Sita Wardani i

DATABASE
Name : Mrs. AA
Age : 25 yo.
Adress : Karang Asem, Sby
Religion : Moslem
Marital Status : Married
Occupation : Elementary School Teacher
Referred from : Neurology Outpatient Clinic with Left
Bells Palsy
 Chief Complain :
Wajah menceng ke kanan
History of Present Illness :
Patients face has been skewed to the right since about a
month ago. It came suddenly when she woke up in the
morning.
She also couldnt close her left eye completely. She felt
dryness on her left eye .
She feels stifness in around her left mouth if she try to smile.
She doesnt feel any numbness sensation or buzzing at her
both ears
She has difficulty to drink because the water always spilled out from
the corner of her left mouth.
She also feels hard to brush her teeth and she has difficulty to gargle.
She feels embarassed to go outside the house due to her condition
right now.
Now the patient is in 39 weeks pregnancy, and her due date is August
28th 2015. She feels worry whether the disease can harm her
pregnancy.
She is now also being treated by Neurology Department since a week
ago, and treated with :
-Alinamin 1x1
-Methylprednisolone 2x4 mg with tappering off
-Mecobalamin 2x1
-CendoLyters 2x3gtt
History of Past Illness :
No history of trauma
No history of Ear Infection
No history of Skin Infection
Patient never experienced same condition like this
before
No history of Hypertension
No history of Diabetes Mellitus
 Physical Examinations :
General Status :
Compos mentis, Independent Ambulation, Normal Gait, Right
Handed Domination
BP : 100/70, HR : 78x/minute
TB : 154cm BB : 56kg
Head and Neck : an-/ic-/cy-/dysp-
Thorax : C/P normal
Abdomen : ovoid shaped compatible with 39 weeks pregnancy,
there are no striae gravidarum or linea nigra,
Extremities : warm acrals, no oedemas
 Musculoskeletal Examinations :
Cervical ROM MMT
Flexion F (0-450) 5
Extension F (0-450) 5
Lateral Flexion F/F (0-450) 5/5
Rotation F/F (0-600) 5/5

Trunk ROM MMT

Flexion F (0-800) 5
Extension F (0-300) 5
Lateral Flexion F/F (0-350) 5/5
Rotation F/F (0-450) 5/5
 Shoulder ROM MMT
Flexion F/F (0-1800) 5/5
Extension F/F (0-600) 5/5
Abduction F/F (0-1800) 5/5
Adduction F/F (0-450) 5/5
Ext. Rotation F/F (0-900) 5/5
Int. Rotation F/F (0-700) 5/5

Elbow ROM MMT

Extension-Flexion F/F (0-1500) 5/5
Forearm supination F/F (0-800) 5/5
Forearm pronation F/F (0-800) 5/5
 Wrist ROM MMT
Flexion F/F (0-800) 5/5
Extension F/F (0-700) 5/5
Radial deviation F/F (0-200) 5/5
Ulnar deviation F/F (0-300) 5/5

Fingers ROM MMT

Flexion
MCP F/F (0-900) 5/5
PIP F/F (0-1000) 5/5
DIP F/F (0-900) 5/5
Extension F/F (0-300) 5/5
Abduction F/F (0-200) 5/5
Adduction F/F (200-0) 5/5
 Thumb ROM MMT
Flexion
MCP F/F (0-900) 5/5
IP F/F (0-800) 5/5
Extension F/F (0-300) 5/5
Abduction F/F (0-700) 5/5
Adduction F/F (500-0) 5/5
Opposition 5/5
Hip ROM MMT
Flexion F/F (0-1200) 5/5
Extension F/F (0-300) 5/5
Abduction F/F (0-450) 5/5
Adduction F/F (0-200) 5/5
Ext. Rotation F/F (0-450) 5/5
Int. Rotation F/F (0-450) 5/5
 Knee ROM MMT
Extension-Flexion F/F (0-1350) 5/5

Ankle ROM MMT

Plantar Flexion F/F (0-500) 5/5
Dorsi Flexion F/F (0-200) 5/5
Inversion F/F (0-350) 5/5
Eversion F/F (0-150) 5/5
 Toes ROM MMT
Flexion
MTP F/F (0-300) 5/5
IP F/F (0-500) 5/5
Extension F/F (0-800) 5/5

Big Toe ROM MMT

Flexion
MTP F/F (0-250) 5/5
IP F/F (0-250) 5/5
Extension F/F (0-800) 5/5
 NEUROLOGICAL EXAMINATION

N. Cranialis I XII : Left peripheral facial nerve (N.VII)

paralysis
Physiological Reflexes :
BPR +2/+2 TPR +2/+2
KPR +2/+2 APR +2/+2
Pathological Reflexes : Babinski -/-,
Hoffman -/-, Tromner -/-
Sensory deficit : No Sensory Deficit

13
Locally status examination
Modified MMT Facial Muscle :
M. Occipitofrontalis : Normal/Poor
M. Corrugator supercilli : Normal/Trace
M. Orbicularis occuli : Normal/Poor
M. Orbicularis oris : Normal/Fair
M. Zygomaticus mayor : Normal/Poor
M. Risorius : Normal/Poor
M. Buccinator : Normal/Poor
Schimmer test : N/N
Taste 2/3 anterior of the tounge :N
Stapedius reflex test : N/N
14
Problem list :
Surgical :-
Medical : - Left Bells Palsy (1 month)
- Pregnancy G1P0-0 39 weeks
Rehabilitation Medicine :
R1 (Mobilitation) :-
R2 (ADL) : Difficulty in drinking, gargling and brushing her teeth
R3 (Communication) :-
R4 (Psychological) : Embarrased because of her condition
Worry about whether the disease can harm her
pregnancy
R5 (Social economy) : -
R6 (Vocational) :-
R7 (Others) : Left Peripheral facial nerve (N.VII ) paralysis
Left facial muscles weakness
Pregnancy G1P0-0 39 weeks
 Diagnosis : Left Bells palsy (1 month) + Pregnancy G1P0-0 39
weeks

Functional Diagnoses :
Impairment : Left peripheral facial nerve (N.VII) paralysis
Left facial muscle weakness
Disability : Difficulty in drinking
Difficulty in brushing her teeth
Handicapped : Shes embarassed to go outside the house for
social occasion like arisan or acara pertemuan
guru due to her condition
Planning :
Surgical : -
Medical : continue the medication from Neurologic Department and
control for Obgyn about her pregnancy
Rehabilitation Medicine
P. Dx :
P.Tx :
- Modality :
Electrical Stimulation in motor point of Left Facial Muscle
-Therapeutic exercise:
Left facial muscle exercise
P.Mx:
Clinical signs and symptoms, MMT for muscles and sensory innervated
by Nervus Facialis
* P. Ed. : Health Education & Home Exercise Program :
- Explain about her condition
- Warm water compress on the left side of the
face
- Facial massage at the left facial muscles
- Facial muscles exercise in front of the mirror
- Facial Y plester on the left face
- Use eye drop (artificial tears) when she feels
dryness on her left eye
- Use plester on her left eye while sleeping
Summary
Reported, female,25 years old, reffered from Neurologic
Department Outpatient Clinic with Left Bells palsy.
Chief complaint was mulut menceng ke kanan. It happened
since about a month ago, it came suddenly when she
woke up in the morning. She had difficulty on drinking,
gargling and brushing her teeth. She cant close her left
eye completely. She felt dryness on her left eye.
From physical examination, the MMT of left facial
muscles were decrease.
Therapy plannings are Electrical Stimulation in motor point of
Left Facial Muscle combine with Therapeutic exercise: Left facial
muscle exercise
Monitoring plannings are Clinical signs and symptoms, MMT for
muscles and sensory innervated by Nervus Facialis
Planning Educations are explain about her condition, warm
water compress, face massage, facial muscles exercise in
front of the mirror at home, inverted Y plester on the left
side of the face, left eye protection, use artificial tears if
theres dryness in her left eye and plester her eye while shes
sleeping.
THANK YOU
 BELLS PALSY
DEFINITION :
Bells palsy is an idiopathic, acute peripheral nerve
palsy, involving the facial nerve, which supplies all the
muscles of facial expression.

Some facts
Risk increase 3-fold in pregnancy
Recurrence rate 8 10%
Diabetes in 5 10%
 Pathophysiology

The pathophysiology of Bell's Palsy is not entirely clear,

but is most likely related to compression of the facial
nerve due to demyelination, inflammation, or ischemia
(inadequate blood supply).
As a result of its convoluted path through the temporal
bone which is only slightly larger in diameter than itself,
the 10,000 neurons that exist in the facial nerve are prone
to impairment due to vascular congestion with secondary
ischemia.
Anatomy of the Facial Nerve
 Location of peripheral lesion :
a) Internal auditory meatus
b) Between internal auditory meatus and
stapedius nerve
c) Between stapedius nerve and chorda
tympani
d) Distal to the chorda tympani
e) After exit from the stylomastoid
foramen
 Clinical symptom
Twitching, weakness, or paralysis on affected side of
the face
The forehead unfurrows
The eyelids will not close
Excessive tearing in one eye
On attempted closure, the eye rolls upward (Bells
phenomenon)
The facial creases and nasolabial fold disappear
The corner of the mouth droops
Drooling
Impairment of taste
 Level Motor Taste Hearing Hypolacrimation

Supra geniculatum + + + +
Geniculi + + + +
Supra stapedius + + + -
Infra stapedius + + - -
Infra chordal + - - -
Pheripheral and Central Lesion
FACIAL MUSCLES
 M. Frontalis raise eyebrow
M. Corrugator
vertical wrinkles at forehead
supercilli
M. Nasalis width nose lobe
M. Orbicularis
close eyes
occuli
M. Orbicularis oris near & pressure both of lips
M. Zygomaticus
smile
mayor
M. Risorius grimace

M. Mentalis upper the chin

Physical Examinations
Muscle Strength Examination with Modified MMT

Persentage Description
100 Full contraction and controlled
4 Good 70-95 Grade

3 Fair 45-65 5 Normal

2 Poor 20-40 Incomplete contraction by maximum try

1 Trace 10-15 Theres contraction but not functional

movement
0 Zero 0 No contraction
 SUPPORTING EXAMINATION :

EMG NCV:
Confirm the presence of nerve damage and
determine the severity and the extend of nerve
involvement.
Differential Diagnosis

Parese NVII peripheral because of trauma or others.

Precaution Factors

Hypertension
Diabetes mellitus
Pregnancy
Severe otalgy
Lack of lacrimation
Skizofrenia
 MANAGEMENT
1. Medical :
Corticosteroid
Neurotropic
NSAIDs

2. Rehabilitation Program :
Infra Red (superficial Heat) for paresis face side
SWD / MWD for foramen stylomastoid area
Electro Stimulation (ES)
Home Exercise Program :
Face Massage and Contraction exercise in front of mirror
Y plester
Eye treatment

3. Surgical:
Decompressi if EMG result total /severe denervation.
 PROGNOSIS

85% achieve complete recovery .

10% some asymmetry of facial muscle.
5% severe sequele.
 Bad Prognostic Factor:
Complete facial palsy
No recovery by three weeks
Age over 60 years
Severe pain
Ramsay Hunt syndrome (herpes zoster
virus)
Associated conditionshypertension,
diabetes, pregnancy
Severe degeneration of the facial nerve
shown by electrophysiological testing
Massage your Face
Massage your face using firm, circular motions with
your hands. Start by your cheeks and work your way
outwards. Move this massage to your forehead, nose and
chin. Massage your entire face for at least 3 minutes in each
area. This will help to improve blood circulation in the
facial muscles as well as tone the muscles in your face.
 EXERCISE
Pucker Your Lips
Pucker your lips as if you were going to kiss someone. Curl the upper lip and try to make it reach the tip of your
nose. Hold for 15 seconds and repeat. Do this at least 10 times to achieve maximum results.
Smile
Smile for 15 seconds while not showing your teeth. Hold it. Then smile for 15 seconds while showing your teeth.
Hold it again. Repeat this process at least four times.
Isolate the Cheek
Put one of your thumbs inside of your mouth, against the inner part of your cheek. Grab the outside of your cheek
with a couple of your fingers; pull down, then push forward on your cheek. Hold it for 10 to 20 seconds, then
repeat. Repeat this process 7 to 10 times.
Work the Chin Muscles
Harden the chin the best you can by making it stick out as if you were taking a punch. Focus all your strength in
tightening these chin muscles and hold it for at least 20 seconds. Rest and repeat this at least 10 times.
Work the Forehead Muscles
Take your two index fingers and move them up to the top of your eyebrows. Firmly put pressure on your eyebrows
as if you were pushing your eyebrows up to your hairline. While applying this pressure, try to close your eyes as hard
as you can for about 15 to 20 seconds. Repeat this process about 7 to 10 times.
Raise Your Eyebrows
Raise your eyebrows as high as you can for 15 to 20 seconds. Release, then repeat about 10 times.