bell' palsy.ppt report.ppt final

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Prepared by: Jobelle Lou M. Okit

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Page 1: Bell' Palsy.ppt Report.ppt FINAL

Prepared by: Jobelle Lou M. Okit

Page 2: Bell' Palsy.ppt Report.ppt FINAL

Bell’s palsy (peripheral facial paralysis, acute benign cranial polyneuritis) is a disorder characterized by a disruption of the motor branches of the facial nerve (CN VII) it is usually temporary with most people making a full recovery within 2-3 months. It comes on suddenly, and the cause is unknown.

Bell's Palsy is diagnosed in approximately 25 of 100,000 people a year. Patients are usually between the ages of 15-60 years old.

The facial nerve (seventh cranial nerve) supplies the muscles in your face. In Bell's palsy this nerve is affected, leading to weakness or paralysis of the muscles that control smiling, frowning, eating and closing of the eyelids. It can also affect your ability to taste.

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• • Bell’s palsy (facial paralysis) is due to unilateral inflammation of the 7th cranial nerve, which result to weakness or paralysis

• The cause is unknown, although possible causes may include vascular ischemia, viral disease ( Herpes simplex, herpes zoster ) autoimmune disease or combination of all these factors.

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• Bell’s palsy is considered by some to present paralysis. The inflamed and edematous become compressed to the point of damage or it’s nutrient vessel is occluded, producing ischemic necrosis to

the nerve.

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• Dizziness • Drooling • Dry mouth • Facial twitching • Hypersensitivity to sound • Inability to blink or close the

eye, tearing, and dry eyes • Impaired sense of taste • Impaired speaking

• Alteration of taste or hearing unilateral loss of facial movement as deadness,

• loss of feeling, or numbness,.• Pain behind the ear

• Decreased tear output/poor tear distribution

• Excessive tearing• Hypersalivation

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• Weakness of the facial muscles• Poor eyelid closure• Aching of the ear or mastoid (60%)• Alteration of taste (57%)• Hyperacusis (30%)• Tingling or numbness of the cheek/mouth• Epiphora• Ocular pain• Blurred vision

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Bell’s palsy may have "myriad neurological symptoms" including

• "facial tingling,• moderate or severe headache/neck pain• memory problems,• balance problems, ipsilateral limb

paresthesias, • ipsilateral limb weakness, • and a sense of clumsiness" that are

"unexplained by facial nerve dysfunction"

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Physical Examination• Initial inspection

– Initial inspection of the patient demonstrates flattening of the forehead and nasolabial fold on the side affected with the palsy. When the patient is asked to raise the eyebrows, the side of the forehead with the palsy will remain flat. When the patient is asked to smile, the face becomes distorted and lateralizes to the side opposite the palsy.

• Otologic examination

– An otologic examination includes pneumatic otoscopy and tuning fork examination. An otologic cause should be considered if the history or physical examination demonstrates evidence of acute or chronic otitis media, including a tympanic membrane perforation, otorrhea, cholesteatoma, or granulation tissue, or if a history of previous ear surgery is noted. Concurrent rash or vesicles along the ear canal, pinna, and mouth should raise the suspicion for Ramsay Hunt syndrome (herpes zoster oticus).

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• The external auditory canal must be inspected for vesicles, injection, infection, or trauma. The patient may have decreased sensation to pinprick in the posterior auricular area. The patient who has paralysis of the stapedius muscle will report hyperacusis. Tympanic membranes should be normal; the presence of inflammation, vesicles, or other signs of infection raises the possibility of complicated otitis media.

• Ocular examination• With weakness/paralysis of the orbicularis oculi muscle (facial nerve innervation)

and normal function of the levator muscle (oculomotor nerve innervation) and Mueller muscle (sympathetic innervation), the patient frequently is not able to close the eye completely on the affected side. On attempted eye closure, the eye rolls upward and inward on the affected side. This is known as Bell phenomenon and is considered a normal response to eye closure.

• The tear reflex may also be absent in many cases of Bell palsy. For these reasons, the patient may have decreased tearing and susceptibility to corneal abrasion and dryness of the eye. The patient may appear to have loss of corneal reflex on the affected side; however, the contralateral eye blinks when testing the corneal reflex on the affected side.

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• Oral examination– A careful oral examination must be performed. Taste and

salivation are affected in many patients with Bell palsy. Taste may be assessed by holding the tongue with gauze and testing each side of the tongue independently with salt, sugar, and vinegar. The mouth must be washed after testing with different substances. The affected side has decreased taste as compared to the normal side.

• Neurologic examination– Careful neurologic examination is necessary in patients

with facial paralysis. Neurologic examination includes complete examination of all the cranial nerves, sensory and motor testing, and cerebellar testing. A neurologic abnormality warrants neurologic referral and further testing, such as MRI of the brain, lumbar puncture, and electromyography (EMG) where appropriate.

• Skin examination– Time must also be taken to examine the patient’s skin for

signs of squamous cell carcinoma, which can invade the facial nerve, and parotid gland disease

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“The degree of nerve damage can be assessed using the House-brackmann score.”

• Grade I - Normal facial function.• Grade II - Mild dysfunction. Slight weakness is noted on

close inspection. The patients may have a slight synkinesis. Normal symmetry and tone is noted at

rest. Forehead motion is moderate to good; complete eye closure is achieved with minimal effort; and slight

mouth asymmetry is noted. • Grade III - Moderate dysfunction. An obvious but not

disfiguring difference is noted between the 2 sides. A noticeable but not severe synkinesis, contracture, or hemifacial spasm is present. Normal symmetry and tone is noted at rest. Forehead movement is slight to moderate; complete eye closure is achieved with effort;

and a slightly weak mouth movement is noted with maximum effort.

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• Grade IV - Moderately severe dysfunction. An obvious weakness and/or disfiguring asymmetry is noted. Symmetry and tone are normal at rest. No forehead motion is observed. Eye closure is incomplete, and an asymmetric mouth is noted with maximal effort.

• Grade V - Severe dysfunction. Only a barely perceptible motion is noted. Asymmetry is noted at rest. No forehead motion is observed. Eye closure is incomplete, and mouth movement is only slight.

• Grade VI - Total paralysis. Gross asymmetry is noted. No movement is noted.

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Magnetic resonance imaging(MRI) Electromyography 

• Electroneurography

• Computed Tomography

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Medical management1. DRUG THERAPY

Corticosteroids (prednisone)Antiviral (Acyclovir )Analgesic

2.SURGICAL OPTIONS includes:– facial nerve decompression, – subocularis oculi fat (SOOF) lift,

implantable devices placed into the eyelid,

– transposition of the temporalis muscle– facial nerve grafting

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• Watch for adverse effects of steroids use• Apply moist heat to the affected side of the

face-to reduce pain• Help the pt. maintain muscle

tone :massaging the face with a gentle upward motion 2-3x daily 5-10mins.

• Exercise by grimacing in front of a mirror 

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• Advise the patient to Protect her eyes, have pt cover eye w/ an eye patch.

• have him chew on unaffected side of his mouth

• Provide a  soft, nutritionally balanced diet, eliminating hot foods & fluids

• Apply a facial sling to improve lip alignment

• Provide frequent & complete mouth care• Offer psychological support

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♪ Disturbed body image related to physical changes due to current illness

♪ Impaired swallowing r/t neuromuscular impairment

♪ Acute pain r/t the inflammation of CN VII

♪ Imbalance nutrition : Less than body requirements r/t inability to chew secondary to muscle weakness

♪ Risk for injury (corneal abrasion) r/t inability to blink.

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• The prognosis for individuals with Bell's palsy is generally very good. The extent of nerve damage determines the extent of recovery.  With or without treatment, most individuals begin to get better within 2 weeks after the initial onset of symptoms and recover completely within 3 to 6 month