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BELL’S PALSY

DEFINITION :
Bell’s 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%
Demographics:
• Race: slightly higher in persons of Japanese
descent.
• Sex: No difference exists
• Age: highest in persons aged 15-45 years. Bell
palsy is less common in those younger than 15
years and in those older than 60 years.
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
Anatomy of the Facial Nerve

(www.aafp.org/afp)
- The facial nerve is a paired structure that coming from
the two nuclei, motorius superior and motorius
inferior, it travels circulate abducent nerve nuclei in the
midbrain, get out from there with intermedius nerve
together and follow through near oktavus nerve to
come inside intern acusticus canal.
- Lateral turn to fallopian canal pars petrosa, inside
timpany cavity post turn. Above foramen ovale its
down follow fallopian canal pars mastoidea. Get out
from skull by stylomastoidea foramina, beneath the
ear, to the muscles on each side of the face.

(Atlas of Neuromuscular disease,)


PATHOPHYSIOLOGY
Compression of facial nerve (entrapment syndrome) at
3 sites:
• Foramen stylomastoid
• Canalis facialis
• Foramen mental
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

(Atlas of Neuromuscular disease)


Clinical sign
• Acute
• Idiopatic
• Parese muscle innervated by N VII perifer type
• Usually unilateral
• Functional impairment (eat, drink)
• Sometimes hyperakusis, decrease in
lacrimation
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 (Bell’s
phenomenon)
• The facial creases and nasolabial fold disappear
• The corner of the mouth droops
• Drooling
• Impairment of taste
(www.aafp.org/afp,http://www.ninds.nih.gov/disorders/bells/detail_bells.htm)
Lesion Level (Topography)

Level Motor Taste Hearing Hypolacrimation

Supra geniculatum + + + +
Geniculi + + + +
Supra stapedius + + + -
Infra stapedius + + - -
Infra chordal + - - -
Peripheral 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
Grade Persentage Description

5 Normal 100 Full contraction and controlled


4 Good 70-95 Full contraction and controlled with a little
added power. Slight decreased of muscle
tone
3 Fair 45-65 Full contraction with maximal trying.
Decreased muscle tone
2 Poor 20-40 Incomplete contraction by maximum try
1 Trace 10-15 There’s 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 N VII 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.
Prognose

• 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 conditions—hypertension, 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.
Sensorik murni
•N.Olfactorius •N.Hypoglossus

•N.Opticus Campuran motorik dan sensorik


•N.Trigeminus
•N.Vestibulococlearis
•N.Fascialis
Motorik murni
•N.Oculomotorius •N.Glossopharyngeus

•N.Trochlearis •N.Vagus

•N.Abducens

•N.Accessorius
The Bell’s Palsy Association
www.bellspalsy.org.uk
ES
SWD