1st

Case
Report
MEDICAL REHABILITATION
IN PATIENT WITH RIGHT
BELL’S PALSY

1
 Introduction
Complex neuromuscular facial disorder of unknown
Bell’s etiology commonly affecting the motor neurones of
palsy facial muscles receiving their neurological
innervations from the seventh cranial nerve

Facial Nerve
motor fibers (including fibers to the stapedius muscle)

autonomic innervations of the lacrimal gland,

submandibular gland
sensation to part of the ear and taste to the anterior two thirds
of the tongue via the chorda tympani
2
The Facial nerve

3
• Annual incidence 15-30 / 100.000
• Female=man, left=right, median age at onset is 40
years, but the disease may occur at any age

CAUSE unknown
viral

Inflammatory
polyneuritis
autoimmune

ischemic
4
 pregnant
women
varicella
zoster diabetes
virus

herpes RISK influenza/

simplex
virus FACTOR cold

exposure to respiratory
air disorder
tooth root
extraction
5
pain in the mastoid region Bell’s phenomenon

Full/partial paralysis one Impaired taste at anterior

side of the face two-thirds of the tongue
corner of the mouth lower lid sags and fall away
droops from conjungtiva
creases and skin folds are
Food collects between the
effaced
teeth and lips
forehead is unfurrowed
Drooling

Lagophtalmus Hyperacusis
6
 TREATMENT
Aims • Speed recovery
(acute phase) • Prevent corneal complications

corticosteroids  < swelling and

inflammation
Medicamentosa AVT  eradication of HSV infection

•Facial exercise or facial

neuromuscular re-education
Medical •Electrostimulation
Rehabilitation •Massage
•Infrared
•Acupuncture
•Eye-protective 7
 TREATMENT

Further • Electroneurography
assessed • Electromyography

• Controversial
Surgical • Within 3 weeks of onset
persistent loss of function at
Decompression
2 weeks
• Latest guideline against the
routine use

8
 COMPLICATION

70 to 80 % recover spontaneously

Up to 95%  recovery without physical

therapy if treated with prednison and AVT
Short-term complication  incomplete eyelid
closure  irritation & corneal ulceration

Long-term complication  permanent facial

weakness, muscle contractures, synkinesis
9
In this case report is
about rehabilitation
in a woman with
Right Bell’s Palsy

10
 Case Report
I. Identity
• Name : Ms. IY
• Age : 21 Years old
• Sex : Female
• Religion : Christian
• Nationality : Indonesian
• Profession : Waitress
• Address : Wanea L.III
• Examination time : May 16th, 2017
11
 II. Anamnesis (Autoanamnesis)
Chief complaint: Right corner of her mouth drooped

History of present illness:

• Right corner of patient’s mouth drooped since 8 days ago
• Right facial creases and nasolabial fold disappeared
• The forehead unfurrowed
• The right corner of the mouth drooped
• Right eyelids couldn’t close
• The food and saliva pooled in the right side and spilled out from the
right corner of the mouth
• Taste food not normal (acid, salty)
• Numbness on her right face
• Felt buzzing on right ear and pain behind right ear
• No history of trauma
• No weaknesses on her arms and her legs
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•First time patient had an experience like this

feeding (chewing
bathing (her food and
right eye always drinking) grooming
slightly opened (gargling
and contacted while tooth
with water and ADL brushing)
soap) disturbances

• 1st and 2nd day vitamin inj

• 3rd day prednisone 20mg 3 times daily
medicine (5 days) 10 mg 3 times daily (5 days)
• ranitidine 150mg 2 times daily
• mecobalamin 500 mg 2 times daily 13
History of past illness:
No history of hypertension, diabetes, toothache, ear
infection, varicella, common cold, and head trauma

Family history:
There is no family member who had this problem

Habitual status:
• Always use a fan directly blow to her face
• Drive motorcycle and using helmet with the glass
cover opened
• No smoking and drink alcohol 14
Social and economical status:
• Patient is a waitress, lives in the boarding house,
squatting toilet, water from well, electricity from
PLN
• Patient pay themselves for the rehabilitation
therapy
Psychological status:
• Adequate orientation to person, place, time and
situation
• Good memory skills and judgment
• Has an anxiety and feels shame about her face
but still has her community activities as usual 15
 III. Physical examination
General Physical Examination
Level of consciousness : compos mentis
Blood pressure: 120/80 mmHg Pulse: 80x/minute;
RR: 20x/minute Temperature: afebrile

Head : no deformity, head in the midline

Hair : black straight hair, hard to be pulled out
Forehead : right side unfurrowed
Eyes : conjunctiva not pale, sclera not icteric, isochoric pupils,
diameter 3 mm/3 mm, right lagopthalmus with gap 3 mm
Nose : no septal deviation, normal nasal mucosa, no secret, no sign of
inflammation
Ear : normal ear canal and tympanic membrane
Nasolabial fold : Right side disappeared
Facial creases : Right side disappeared
Mouth : Right corner of mouth dropped 16
Oral cavity : good oral hygiene, normal oropharynx
Throat : T1/T1, no hyperemic, symmetric arc of
pharynx, no deviation of uvula
Chest : symmetrical shape in static and dynamic
Pulmo : symmetrical breathing, sonor on both side,
no ronchi, no wheezing
Heart : normal heart sound I-II, no murmur, no
gallop
Abdomen : no defense muscular, no enlargement of
liver and spleen, tympanic sound on
percussion, normal peristaltic sound
17
Neuromuscular Examination
Cranial Nerve Examination : All within normal limit except CN VII

CN VII (Facial)
Inspection : facial was asymmetry
Raising eyebrows : asymmetric, right eyebrow was left behind
Frowning : asymmetric, left side was more visible than
right side
Closing eyes : abnormal, gap visible in right eye 3 mm
Smiling : asymmetric, right corner of mouth was left
behind
Pursuing lips : asymmetric, right side of mouth was
inadequate
Puffing-up cheeks : asymmetric, left side was larger
Sense of taste on 2/3 anterior tongue : abnormal (acid, salty)
Impression : abnormal
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 Local Status Regio Facial
Look: facial Feel: kalor (-),
Move: limited at
asymmetry, edema (-),
right side, pain(-)
rubor (-) tenderness (-)

Raising eyebrows: asymmetric, right eyebrow was left behind

Frowning: asymmetric, left side was more visible than right side

Closing eyes: abnormal, right lagopthalmus with gap 3 mm

Smiling: asymmetric, right corner of mouth was left behind

Pursuing lips: asymmetric, right side of mouth was inadequate

Puffing-up cheeks: asymmetric, left side was larger 19

Table 1. Manual Muscle Test of Facial Muscles

Muscles Right Left

Frontalis 0 3

Corrugator supercilli 0 3

Procerrus 1 3

Orbicularis occuli 1 3

Zygomaticus mayor 1 3

Buccinators 1 3

Orbicularis oris 1 3
20
 Table 2.UGO FISCH scale
Position Value Percentage Score

Rest 20 70 14

Frown the forehead 10 30 3

Closed eyes 30 30 9

Smile 30 30 9

Whistle 10 30 3

Total 38
21
 House-Brackmann score to grade severity of facial nerve
palsy by assessing motility of forehead, eye, nose, and
mouth as 1-6
Grade Score
Normal, symmetrical function in all areas I
Slight weakness on close inspection, complete eye closure with minimal effort, slight II
asymmetry of smile with maximal effort, slight synkinesis, absent contracture or spasm

Obvious weakness but not disfiguring, unable to lift eyebrow, complete and strong eye III
closure, asymmetrical mouth movement with maximal effort, obvious but not disfiguring
synkinesis, mass movement or spasm
Obvious disfiguring weakness, inability to lift eyebrow, incomplete IV
eye closure, and asymmetry of mouth with maximal effort, severe synkinesis, mass
movement, spasms
Motion barely perceptible, incomplete eye closure, slight movement corner of mouth, V
synkinesis, spasm usually absent
No movement, loss of tone, no synkinesis, contracture, spasm VI
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 May 16th 2017 (on first visit)

At rest M.Frontalis M.Corrugator

supercilli
23
M.Procerus M.Zygomaticus M.Orbicularis
mayor occuli

24
M.Orbicularis M.Buccinators
oris
25
21 years old female patient came to Physical Medicine and Rehabilitation
Department on May 16th, 2017 with chief complaint of right corner of her
mouth dropped
 Asymmetry of face (+)
 Facial sensation is preserved
 History of buzzing sound in the right ear (+)
 Pain behind right ear
 This is the first time patient had an experience like this
 Medicine from neurologist: prednison, ranitidin, and mecobalamin
 Shame and worry but still had her community activities as usual

On physical examination:
 compos mentis with normal vital signs
 Paresis of right peripheral 7th cranial nerve
 Sense of taste on 2/3 anterior tongue is abnormal (acid,salty)
 Manual Muscle Test of all facial muscles was 1 except for M. Frontalis and M.
Corrugator supercilli was 0
 UGO FISCH Scale was 38
 House-brackmann’s score was grade IV 26
 Diagnosis
Clinical diagnosis : Right Bell’s palsy 8th days of onset

Topical diagnosis : Facial nerve at right middle ear portion

Etiologic diagnosis : Idiopathic

Functional diagnosis:
• Body function
• Body structure
• Activity
• Environment
• Personal factor
: weakness at right facial muscle, gap of right eye 3 mm, Sense of
taste on 2/3 anterior tongue is abnormal (acid,salty)
: Facial nerve at right middle ear portion
: Limitation on chewing, gargling, drinking, and closing eye
while bathing and sleeping
: using fan in bedroom, using helmet with the glass cover opened
: age 21 years old, anxiety and shame about her face,
habit to let the fan blow directly to her face while sleeping
and open the glass cover of the helmet while driving
motorcycle
27
 Problems
Limitation in facial expressions (raising eyebrows,
frowning, closing eyes, smiling, pursuing lips and puffing-
up cheeks) because of weaknesses on the right side of face
(Manual Muscle Test of all facial muscles was 1 except for
M. Frontalis and M. Corrugator supercilli was 0 day 8th

Gap of right eye: 3 mm

Limitation on activity daily living (ADL) such as chewing,

gargling, drinking, and closing eye while bathing and
sleeping

Anxiety and shame about her face

28
 To educate and reassure the
patient about the condition

To facilitate or
To prevent
complications
Goals improve muscle
contraction

To facilitate or
improve facial
symmetry 29
 Physiatrist : PROGRAM
• Education (its causes, Don’t expose her eyes to
Use artificial direct sunlight, being too
incidence, prognosis and tears close to television light, or
treatment) strong room lighting
• Re-assure the patient
Wear sun glasses to Don’t exhaust eyes
• Give advice by reading for long
protect eyes in
• For eyes outdoor daylight time
• avoid any emotional
conflict Avoid direct contact While patient is
• Follow the given home with air conditioners about to sleep, close
and wind, close the the right eye
program glass cover of passively with hands
• Using BPJS helmet while riding and use eye cover or
motorcycle patch.
• Medication : artificial tears
1-2 drops 3 times daily at While patient is bathing, close the
the right eye right eye passively with hands.
30
 Physiotherapy
Deep kneading massage on her right face start at day 8th of
onset

Modality: Infrared on her right face start at day 8th of onset

Neuromuscular retraining on facial muscles in front of the

mirror start at day 8th of onset

Electric stimulation after 2 weeks onset

Psychology
Mental support
31
 Home program
• Warm compress on the right side of face for 10-15
minutes daily
• Massage on the right side of face start at day 8thof onset
• Neuromuscular retraining on facial muscles in front of
the mirror
• Blowing candle exercise, use straw while drinking, and
gargle training

Advises and assisted family and friends in modifying home

environment to support her treatment stop using fan
directly to face and suggest to using BPJS 32
` May 23rd, 2017 (day 15th of onset)
S Asymmetry of the face, decreasing pain at region mastoid

O Muscles Right Left

Frontalis 1 3
Corrugator supercilli 1 3
Procerrus 1 3
Orbicularis occuli 1 3
Zygomaticus mayor 2 3
Buccinators 1 3
Orbicularis oris 1 3
Position Value % Score
Rest 20 70 14
Frown the forehead 10 70 7
Closed eyes 30 30 9
Smile 30 70 21
Whistle 10 30 3
Total 54
House-Brackmann: grade IV
33
A Right Bell’s palsy day 15th
P Rehabilitation program:
- Infrared on the right face
- Deep kneading massage on her right face
- Neuromuscular retraining of right facial muscles in front of
the mirror
- Home program: warm compress on the right side of face for
10-15 minutes daily, massage on the right side of face,
neuromuscular retraining of right facial muscles in front of
the mirror daily, blowing candle, use straw while drinking,
and gargle training
- Education: use artificial tears on right eye daily, use eye
cover while sleep, use sunglasses at daytime, close the glass
cover of helmet while riding motorcycle
- Mental support for patient

34
 June 20th, 2017 (day 34th of onset)
S Patient could closed both eyes tightly, drinking water and gargling without spilled
at right corner of mouth. Symmetry of the face when resting position, but still
asimetrical when whistling
O Muscles Right Left
Frontalis 3 3
Corrugator supercilli 2 3
Procerrus 2 3
Orbicularis occuli 3 3
Zygomaticus mayor 3 3
Buccinators 3 3
Orbicularis oris 2 3
Position Value % Score
Rest 20 100 20
Frown the forehead 10 100 10
Closed eyes 30 100 30
Smile 30 100 30
Whistle 10 70 7
Total 97
House-Brackmann: grade II
A Right Bell’s palsy day 34th
P The program continued 35
June 20th 2017 (day 34th of onset)

36
37
38
 Discussion
Anamnesis Diagnosis Physical
examination

Asymmetry at the right side of  MMT of all right facial

face since 8 days ago
Bell’s phenomenon
Habits: fan blowing directly to
face
Could not taste food normally
No history of trauma
No weaknesses on extremity
First time experience
muscles was 1 except for M.
Frontalis and M. Corrugator
supercilli was 0
 Sense of taste on 2/3
anterior tongue is abnormal
(acid,salty)
 House-Brackmann grade was
IV
 UGO FISCH scale was 38
 Lagopthalmus at the right
eye: 3 mm 39
House–Brackmann facial nerve grading system

• clinically assess the severity
• provides prognostic information for facial
recovery
• most widely applied

In this patient:
HBS IV (day 8)  HBS II (day 34)
40
 UGO FISCH Scale
• Assess the condition of symmetric or asymmetric at 5
positions
• 0% (asymmetrical)
• 30% (symmetrical, poor, the recovery is likely closer to
complete asymmetrical)
• 70% (symmetrical, fair, partial recovery is likely closer to
complete symmetrical)
• 100% (symmetrical, normal or complete)

In this patient
UGO FISCH Scale: 38 (day 8)  97
(day 34) 41
 DIFFERENTIAL DIAGNOSIS
• Lyme disease
• Ramsay Hunt syndrome
• Guillain-Barré syndrome
• Leprosy
• Facial neuropathy in diabetes mellitus, amyloidosis
• Acoustic neuromas
• Infarcts, demyelinating lesions of multiple sclerosis, and
tumors in pontine
• Tumors that invade the temporal bone (carotid body,
cholesteatoma, dermoid)
• UMN lesions of the facial nerve
42
• Family history of diabetic, obesity, older than 30
years  fasting glucose or A1C testing
• Lyme antibody titers  history possible exposure
• Onset or forehead sparing  imaging of the head
• Complete facial paralysis electroneurography or
electromyography (EMG)
• denervation and/or reinnervation ,
• degree of recruitment of motor units
• evaluating the facial muscle status whether there is complete
muscle fibrosis or there are still viable contractile muscle
fibers

• Bilateral palsies and not improve within the first 2-

3 weeks after onset referred to a neurologist
43
 Medicaments Rehabilitation
• Corticosteroids < inflammatory process,
facilitates remyelination.
• <72 hours duration
• Dose 60 mg/day (5 days)reduced by 10 mg 3
times daily (total treatment time of 10 days).

Patient had already taken prednisone from neurology

department since day 3th with dose 20 mg 3 times daily
(5 days ), followed 10 mg 3 times daily (5 days) 44
• Antiviral treatment (Acyclovir or Valacyclovir)
eradication of HSV infection
• Not statistically significant
• Bell’s palsy is a post-infectious immune mediated
facial neuropathy rather than direct viral infection
• Latest guideline  suggest antiviral +
corticosteroids in severe to complete paresis

This patient was not given AVT from neurology

department
45
• injection of 500 µg of vitamin B12
(methylcobalamin) given 3 times weekly for at
least 8 weeks was of benefit in enhancing
recovery in Bell’s Palsy

This patient was given mecobalamin 500mg 3

times daily from Neurology Department

46
• eye-protective measures  recommendation
to prevent corneal complication
• Lubricating drops
• Ocular patches

• This patient was given artificial tears

regularly during the day and suggested to
passively closed her eyes with finger and
used eye patches before sleep
47
• Local superficial heat therapy (hot pack or infrared rays) for 15 min/session
 improves local circulation
• Massage improves circulation and may prevent contracture.
• 10 repetitions 1 or 2 times per day
• the latest guideline
 recommendation to give physiotherapy for persistent weakness
 no recommendation for acute Bell’s Palsy of any severity.

This patient was given infrared rays and facial massage at the 8th
day of paralysis onset
T h e st a ge s o f B e l l ’s p a l sy
resting restoration
acute stage
stage (8-20 stage (21-
(1-7 day)
days) 90 days). 48
• Facial neuromuscular re-education  relearning facial movement
using specific and accurate feedback

initiation • actively assisting specific facial movements, avoid mass movement

patterns.
facilitation • active and resistive exercise to increase facial movement excursion and
facilitating the affected-sided musculature.
movement control • meditation-relaxation strategies , controlling synkinetic movements

Relaxation • In severe pan-facial tightness attributable to synkinesis and hypertonicity

This patient no signs of synkinesis or facial tightness 

neuromuscular re-education performed at initiation and
facilitation phase only
49
 Electrical stimulation
reinforces abnormal (synkinetic) patterns, may be disruptive to
reinnervation, enhancing contracture, increasing cost of treatment

preserving muscle bulk (in complete paralysis), psychological benefit,

enhance axonal regeneration and skeletal muscle reinnervation

• Faradic stimulation until voluntary facial movement (+) and if

contracture or synkinesis (+)
• Latest guideline suggest against the use of ES in acute Bell’s palsy at
any severity

This patient was not given ES on her initial

examination and the next follow up due to well
recovery facial muscle and consideration of the
risk and benefit of the treatment itself 50
• In the past, surgical decompression within 3
weeks of onset  recommended (persistent loss
of function at 2 weeks)
hearing
loss
leaks of further
CSF damage
Risks

• Benefit no evidence!
• Latest guideline suggest against the routine use of
surgical decompression as a treatment choice in
Bell’s palsy 51
• installation of the “Y” plaster in the corner of
the mouth
• performed within 3 months if there has been
no change in patients after undergoing
physiotherapy.

This patient didn’t use the “Y” plaster due

to full recovery at the next month follow up

52
• 80–85% recover spontaneously and completely within
3 months
• 15–20% permanent nerve damage
• 5% severe sequelae  persisting weakness, contractures,
facial spasms, synkinesis, decreased tearing, crocodile tears,
or psychosocial effects

53
• At 1st visit: anxiety and felt shame 
education, re-assured and consulted her to a
psycholog  shame and anxiety << gradually
 first follow up: no psychology problem
• At the 34th days of onset  recovery almost
completely (UGO FISCH 97 and HBS grade II)
physical therapy continued and education
(possible complication or recurrence)

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64
Instructions to Patient: "Frown. Don't let me
erase it."
s