Bell

BELL’S PALSY

Bell’s palsy, or idiopathic facial paralysis, is a form of facial Paralysis resulting from dysfunction cranial nerve VII (the facial nerve) that result in the inability to control facial muscles on the affected side. It is named after Scottish anatomist CHARLES BELL.

Bell’s palsy is the most common acute mononeuropathy and is the common cause acute facial nerve paralysis. Several conditions can cause facial paralysis Eg: brain tumor, stroke, Lyme disease.

Statistics, both males and females are equally affected and recovered. The annual incidence of Bell’s palsy is about 20 per 100,000 population and incidence increases with age. It affects approximately 1 person in 65 during life time. Familial inheritance has been found 4-14% of cases. It is three times more likely to found in pregnant than non-pregnant women. It is four times more likely occur in diabetics than the general population.

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Bell’s palsy is diagnosed by bell’s phenomenon. A warning sign may be neck pain or pain in or behind the ear prior to palsy, but it is not usually recognized in first time cases.

Treatment of Bell’s palsy is variable, ranging from observation to surgical decompression. Physiotherapy plays an important role in bell’s palsy ,electrical stimulation to stimulate muscles and to maintain its properties, massage therapy ,facial exercise to improve strength and co-ordination ,and finally home program is given for progression of treatment this may cause recovery from bell’s palsy.

Approximately 50% of Bell’s palsy patients will have essentially complete recoveries in a short time another 35% will have good recoveries in less than a year.

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ANATOMY

Facial Nerve:

This is the seventh cranial nerve

It is the nerve of second brachial arch.

Nuclei:

The fibers of this nerve arise from four nuclei, situated in the lower part of the pons.

a) Motor Nucleus:

It gives special visceral efferent fibers to the muscles responsible for facial expression and for evaluation of hyoid bone.

b).Superior Salivatory Nucleus:

It gives general visceral efferent fibers.

(These fibers also arises from motor nucleus) are secretomotor to the submandibular and sublingual salivary glans, the lacrimal glands and the glands of the nose, the palate and pharynx.

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c).Nucleus Tractus Solitarius:

It gives special visceral afferent fibers that carry taste sensations from the anterior 2/3rd of the tongue and from the palate.

d).Lacrimatory Nucleus (Parasympathetic):

It gives ‘general somaticafferent fibers’ innervate a part of skin of the ear.

Course and relations:

The facial nerve is attached to the brain stem by two roots.

1) Motor 2) Sensory

> The sensory root is also called the Nervous Intermedius.

> The two roots of the facial nerve are attached to the lateral part of the lower border of the pons.

> The two roots run laterally and forwards to reach the internal acoustic meatus.

> In the acoustic meatus the motor root lies in the groove with the sensory root intervening.

> At the bottom of the meatus the two roots (Sensory & Motor) fuse to form a single trunk, which lies in the pectrous temporal bone.

> With in the canal the course of the nerve will be divided into 3 parts by two bends.

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> The first part is directed laterally above the vestibule. The second part runs backwards in the medial wall of the middle ear, above the promontory.

> The third part is behind the promontory.

> The first bed is present anterior-superior part of the promontory and is also called as genu. The second bend lies between the promontory and the auditus to the mastoid antrum.

The facial nerve leaves the skull by passing through the stylomastoid foramen.

IN this extra cranial course it crosses the lateral side of the base of the styloid process enters the posterior-medial surface of the parotid gland and runs forward through the gland.

Behind the neck of the mandible it divides into 5 terminal branches which emerge along the anterior border of the parotid gland.

Branches & Distribution:

a) With in the facial canal:

1) Greater petrosal nerve: It arises from the geniculate ganglion of the facial nerve carries gustatory and parasympathetic fibers.

2) The nerve to the stapedius: Arises opposite the pyramid of the middle ear and supplies the stapedius muscle.

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3) The chorda tympani: Arises in the vertical part of the facial canal, and it supplies anterior 2/3rd of the tongue

b) At it exists from stylomastoid foramen:

1) Posterior auricular nerve: Arises just below the stylomastoid foramen and supplies the auricularis posterior. The occipitalis and the intrinsic muscles of the back of the auricle.

2) The digastric branch: Arises just below the stylomastoid foramen and supplies, the posterior belly of diagsric muscle.

3) Stylomastoid branch: Arises just below the stylomastoid foramen and supplies stylomastoid muscle.

c) Terminal branches: With in the parotid glands.

1) Temporal branch: Supplies auricularis anterior.

The intrinsic muscles on the lateral side of the ear.

Frontalis Orbicularis occuli Corrugator supercili2) Zygomatic branch: Supplies the orbicularis occuli.

3) Buccal Branch: Supplies the buccinator muscle elevators of the upper lip and the orbicularis oris.

4) Mandibular branch: Supplies the muscles of lower lip and chin.

5) Cervical Branch: Supplies platysma.

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Communicating branchs: For effective coordination between the movements of the 1st, 2nd, 3rd branchial arches.

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MYOLOGY

Facial Muscles:

Epicranial Musculature:

1) Occipitalis

Origin: Occipital bone and mastoid process.

Insertion: Galea aponeurotica

Action: Moves scalp backwards.

2) Frontalis

Origin: Galea aponeurotica.

Insertion: Skin of eyebrow.

Action: Wrinkles on forehead and elevates the eyebrows.

Orbital Musculature:

Orbicularis Occuli:

Origin: Bones of medial orbit.

Insertion: Tissue of eyelid.

Action: Closes eyes.

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1) Corrugator supercilli

Origin: Fascia above eyebrow.

Insertion: Root of the nose.

Action: Draws eyebrows forwards midline.

Nasal Musculature:

1) Nasal Procerus

Origin: Fascia over the nasal bone

Insertion: Into the skin immediately above the ridge of the nose.

Action: Horizontal wrinkles over the nose.

Nasalis:

Its has two parts

a) Compressor naris

b) Dilator Naris.

a) Compressor Naris

Origin: Lateral Margin of anterior nasal aperture

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Insertion: Continues with the same fiber from the opposite side.

Action: Compresses the anterior apertures

b) Dilator naris

Origin: Lateral margin of the anterior nasal aperture

Insertion: Ala of nose

Action: Dilates anterior nasal aperture

Depressor septi nasi

Origin: Upper incisive fossa

Insertion: Lower and anterior part of the nasal septum

Action: Depression of the nasal septum

Auricular Musculature:

1) Rudimentary

2) Auricularis

a) Superior

b) Anterior

c) Posterior

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Oral musculature:

a) Superficial

b) Deep

a) Superficial:

1. Levator labi superioris

Origin: Upper maxilla and zygomatic bone

Insertion: Orbicularis oris and skin above lips

Action: Elevates upper lip

2. Levator labi superioris aleqi nasi

Origin: Frontal process of maxilla

Insertion: Skin of upper lip

Action: Elevation of upper lip

3. Orbicularis oris

Origin: Fascia surrounding lips

Insertion: Mucosa of lips

Action: Closes and purses the lips

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4. Zygomatis major &minor

Origin: Anterior surface of zygoma

Insertion: Superficial striata of orbicularis oris

Action: Elevates corner of mouth

5. Depressor labi inferioris

Origin: Anterior part of oblique line of mandible

Insertion: Into lower lip

Action: Depresses the lower lip

6. Depressor anguli oris

Origin: Posterior part of oblique line of mandible

Insertion: Lower lip mouth

Action: Depresses the lower lip

7. Risorious

Origin: Fascia over parotid salivary gland

Insertion: Superior striata of orbicularis oris

Action: Draws angle of mouth laterally

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b) Deep:

1. Levator anguli oris

Origin: From maxilla just below the intra orbital foramen

Insertion: Into the orbicularis oris

Action: Elevates the upper lip

2. Incisivus labi superioris

Origin: Lateral part of incisive fossa

Insertion: Into the skin of upper lip

Action: Changes the shape and form of lips

3. Mentalis

Origin: Mental protuberance

Insertion: Into the lower lip

Action: Elevates and protrudes the lower lip

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4. Buccinator:

Origin: Alveolar process of maxilla mandible

Insertion: Into the orbicularis oris

Action: Compresses cheek

Nerve supply: All the above muscles are supplied by facial nerve

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PHYSIOLOGY

Nervous system controls all the activities of the body. Neuron is defined as the structural and functional unit of

the nervous system. Depending upon the length of the axon neuron are divide

into

1. Golgi type-1

2. Golgi type-2 neuron

In the central and peripheral nervous system the neuron has almost alike structure, with nerve cell body dendrite and axon.

Nerve cell body has nucleus, nissal granules and axon hillock.

Dendrites are the branched processes of the neuron, they are afferents.

The axon is the longer process of the nerve cell arising from axon hillock, which acts as efferent.

The nerve is covered by epineurium, fasciculus is covered by perineurium and each fiber is covered by endoneurium.

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Properties of nerve fibers:

The properties of nerve fiber are

1.Exitability

2.Conductivity

3.Refractory period

4.Summation

5.Adaptability

6.Infatigability

7. All or none law

1. Exitability:

It is defined as the physiochemical change that occur in a tissue when a stimulus is applied.

The stimulus is defined as an external agent, which produces excitability in the tissues.

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Action potential:

When the nerve is stimulated, a series of changes occur in the membrane potential, which is together called as action potentials.

If depolarization at a spot on the cell reaches the threshold voltage, the reduced voltage now opens up hundreds of voltage gated channels in that portion of the plasma membrane. During the millisecond that the channels remain open, some 7000Na+ rushes into the cell. The sudden complete depolarization of the membrane opens up

more of the voltage-gated channels in adjacent portions of the membrane. In this way, a wave of depolarization sweeps along the cell. This is the action potential. (In neurons, the action potential is also called the nerve impulse)

2. Conductivity:

The action potential is transmitted through the nerve fiber as nerve impulse.

The action potential is transmitted through the nerve fiber in only one direction.

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3. Refractory period:

It is the period at which the nerve does not give any response to a stimulus.

4. Summation:

When one stimulus is applied, it does not produce any response in the nerve fiber.However, if two or more subliminal stimuli are applied within a short interval of about 0.5msec, the response is produced .It is because the subliminal stimuli are summed up together. This phenomenon is known as Summation.

5. Adaptation:

While stimulating a nerve fiber continuosly, the excitability is maximum in the beginning. Later the response decreases slowly and finally the nerve finally the nerve fiber doesn’t show any response .This phenomenon is known as adaptation or accommodation.

6. Infatigability:

A nerve fiber cannot be fatigued, even if it is stimulated continuously for a long time. The reason is the nerve can conduct only one action potential at a time. At that time, it is completely refractory and doesn’t conduct another action potential.

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7. All or none law:

When a nerve is stimulated by a stimulus with sub threshold strength, action potential doesn’t develop. If the strength of stimulus is above the sub threshold level, whatever may be the strength of stimulus, the amplitude of action potential remains same .This is known as all or none law.

Synapse:

The junction between the two neurons is called as synapse.

It may be classified anatomically or functionally

Anatomical classification:

Depending upon the ending of the axon, the synapse is classified into 3 types.

1. Axosomatic synapse

2. Axodentritic synapse

3. Axoaxonic synapse

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On the basis of transmission of impulses, the synapse is classified into

1. Electrical synapse

2. Chemical synapse

Electrical synapse:

In this, there is continuity between the pre&post synaptic neurons.

>The continuity is provided by gap junction between the two neurons.

>There is minimal synaptic delay because of the direct flow of current.

Chemical synapse:

In this there is no continuity between the pre & post synaptic neuron because of presence of a space called synaptic cleft between two neurons.

Properties of synapse:

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1. One way conduction:

The impulses are transmitted only in one direction in synapse

2. Synaptic delay:

During the transmission of impulses via the synapse, there is a little delay in the transmission.

3. Fatigue:

During continuous muscular activity the synapse forms seat of fatigue.

4. Summation:

When many numbers of presynaptic excitatory terminals are stimulated simultaneously or rapidly, there are summation or fusion effects in post synaptic neurons. Summation is partial or temporal.

5. Electrical property:

These are the excitatory post-synaptic and inhibitory post-synaptic potential.

Neurotransmitters:

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The chemical mediator substances responsible for the transmission of impulses through a synapse.They are

Acetyl cholineAmines like

nor adrenaline Dopamine Seratonine HistamineAmino acids like

Gamma amino buteric acid(GABA) Glycin Glutamate Aspertate Substance-P Encephaline

Types of neurotransmitters:

1. Excitatory2. Inhibitory

Reflex arch:

The anatomical nervous pathway for a reflex action is called reflex arch.

Mechanism:

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From the receptor the impulses are transmitted through the afferent nerve & they are transmitted through the afferent nerve & they are transmitted to the center i.e to the cerebellar/ cortical reflexes & from there the descending impulses are transmitted to the efferent nerve to the efferent organ that is to the muscle.

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ETIOLOGY

Bell’s palsy is caused by an inflammation of the facial nerve where it exists the skull within its bony canal (fallopian canal), blocking the transmission of neural signals because the width of the canal is smaller at its proximalpart, the nerve is thicker at that point because it contains more nerve fibers.

Viral and bacterial infection as well as auto immune disorders appears to be emerging as the most frequent common threat in etiology of bell’s palsy.

Herpes simplex-1:

The triggers for reactivation of the virus prior to the set of bell’s palsy have not been proven conclusively

Impaired immunity Herpes zoster.

Temporary causes:

Stress Lack of sleep Minor illness Physical trauma. Upper respiratory infection.

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Long term causes:

Auto immune disorders. Chronic diseases etc., are strongly targeted as the most

likely triggers Viruses including cytomegalovirus, Epstein-Barr rubella Mumps

Ramsey hunt syndrome:

HIV/ AIDS increase the chance of developing of Bell’s palsy.

Exposure to chill or cold weather causes compression of facial nerve.

Fracture of mastoid Craniotomy (surgery induced). Infection of internal ear (otitis media). Road traffic accidents. Trauma due to blunt force. Temporal bone fracture. Brain stem injuries. Acoustic neuroma. Cysts and tumors. Diabetes. Thyroid conditions. Lupus, stogerms syndrome. Congenital defects.

Tooth extracts.

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PATHOLOGY

Lower motor neurons:

Bell’s palsy is a LMN lesion LMN are the anterior gray horn cells in the spinal cord

and the motor neuron of the cranial nerve nuclei in the brain stem which innervate the muscles directly.

Thus the lower motor neurons constitute the final common pathway of motor system.

Lower motor neuron is under the influence of upper motor neurons.

Effects of LMN lesion:

Clinical observations:

Muscle tone-hypotonic

Paralysis-flaccid type. Wasting of muscle. Superficial reflexes are lost. Plantar reflexes are absent. Deep reflexes are lost. Clonus is absent.

Clinical confirmation:

Electrical activity is absent Individual muscles are affected. Fascicular twitch in EMG is present.

Types of LMN lesion:

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Peripheral nerve fiber lesion damage to a LMN involve either the anterior horn cells or the fibers of the nerve roots or peripheral nerves, lesions involving the nerve fibers can be classified into

1. Neuropraxia.2. Axontemesis.3. Neurotemesis.

Neuopraxia (1 ST degree injury):

It is a condition in which bruising or pressure renders the nerve in capable of conducting impulses. Past the site of the lesion. Degeneration does not occur.

Axonotemsis (2 nd degree injury):

It is liable to occur if the lesion is more severe. Degeneration of the axon takes place. The sheath of the nerve remains intact.

Neurotemsis (3 rd degree injury):

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It is sever, the nerve sheath and fibers are not in intact, the fibers degenerate below the site of the lesion, the condition is more serious as suture of the nerve is necessary before satisfactory nerve regeneration takes place.

All these types of lesion may be partial or complete and there may be a combination of two of them.

The facial nerve becomes swollen and hyperaemic with in the facial canal, in which there is

limited space. The nerve rapidly becomes compressed and conductivity is lost.

Regeneration:

The degenerated nerve fiber may be regenerated. The regeneration of the injured nerve can occur only under favorable conditions regeneration starts early as 4th day after injury, but becomes more effective only after 30 days and is completed about 80 days.

The regeneration of the nerve fiber occurs if the following criteria are fulfilled.

1. The gap between the cut end of the nerve should not exceed 3mm.

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2. The neurilemma should be present. As neurilemma is absent in central nervous system, the regeneration of nerve does not occur in CNS.

3. The nucleus must be intact. If the extruded from nerve cell body, the nerve is atrophied and, the generation does not occur.

4. The two ends should remain in the same line. Regeneration does not occur if any one end is moved away.

Stages of Regeneration:

1) First the cells of Schwann from the proximal and distal cut ends of the nerve grow out in all directions in the form of Pseudopodia like fibrils. The number of the fibrils is up to 100. The fibril from one end established contact with the fibrils of the other end and fill up the gap between two cut ends of the nerve. The activity of the proliferation schwann cells is greater in distal end than in proximal end. The filling up of the gap leads to the development of continuity of neurilemmma tube.

2) Later, the axis cylinder is fully established inside the neurilemmal tube. These processes are complete in about 3 months after injury.

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3) The myelin sheath is formed by the cells of Schwann slowly. The myelination is completed in one year.

4) The diameter of the nerve fiber gradually increases. However the degenerated nerve fiber obtains only 80% of original diameter.

5) In the nerve cell body, first the nissal granules appear followed by golgi apparatus.

6) The cell looses the exceeds fluid the nucleus occupies the central portion.

7) Though the anatomical regeneration occurs in the nerve, the functional recovery occurs after a long period.

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CLINICAL FEATURES

The VIIth facial cranial nerve has both motor and sensory functions.

Its motor functions include shutting the eye, lifting the eyebrow, and supplying the muscles that move the mouth and lips.

Its sensory functions include tasting on the front of the tongue and dampening the level of the sound we hear.

So the symptoms of Bell’s palsy include any abnormalities involving these various muscles.

Many people describe feeling a pain behind their ear or near the jaw a few days before the other symptoms develop. Symptoms begin suddenly and hit their peak usually with in 48 hours.

Seventy Five percent of cases are preceded by upper respiratory infection or a viral infection.

Clinical Features:

The most common symptom of Bell’s palsy is weakness on one entire side of the face. Sudden one sided facial paralysis or weakness of the facial muscles.

A person may not be able to close one eye, inability to blink, or they may have difficulty shutting their eye completely. Diminished blinking and the absence of tearing together can

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reduce or eliminate the flow of tears across the eyeball, resulting in drying, erosion, and ulcer formation on the cornea and possible loss of the eye.

The forehead doesn’t wrinkle when a person tries to lift their eyebrow.

The lower part of the face may drop down. Patients aren’t able to lift their mouths to smile or fill

their cheeks with air. They may drool from the mouth. Some people may feel a tingling, twitching or

numbness in the face. Face feels stiff or pulled to one side, change in facial appearance, difficulty with facial expression, grimacing etc, difficulty with fine facial movements, asymmetrical smile.

Dry eyes or tearing (crocodile tears). Pain in the back of the head, ear, behind the ear, or

the affected side of the face. Hypersensitivity to sound (hyperacusis) or hearing

deficit. Dry mouth and impairment of taste. Difficulty with eating and drinking. Speech is affected. Nose feels stuffed or blocked, or runs. Pain in or near the ear. Blisters in the ear. Fatigue and dizziness (vertigo). Tooth decay and gum disease due to reduced saliva

and impairment of chewing.

INVESTIGATIONS

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STRENGTH DURATION CURVE:

Introduction:

The plotting of strength duration curve is the most satisfactory method at present available for the routine testing of electrical reaction in nerve lesion.

Apparatus:

Electrical stimulator (muscle)

Rectangular impulses of different duration of 0.01, 0.03 0.1, 0.3, 1, 3, 10, 30 & 100 milli seconds are required.

Technique:

Before applying the current, the skin resistance is reduced. An inactive electrode is placed on the nape of the neck at spinal cord level. Active electrode is placed on the motor point of the muscle current is applied, using the largest stimulus first and increased until a minimal current is obtained. A minimal contraction is used, as this makes it easy to detect any change in strength. Next the duration is decreased and gradually intensity is increased and when

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minimal contraction is noted the graph is plotted against duration on x-axis and intensity on y- axis.

Kink:

An easy sign of re-innervation of the nerve supply to a muscle may change in the shape of the strength duration curve and as re- innervating progresses the curve moves down and to the left. Progressive denervation is indicated by the appearance of a kink. Kink is the point where the innervated and denervated muscles section meets. Kink in the graph shows partial innervation.

Advantages:

It is the simple and reliable method and indicates the proportion of denervation.

Disadvantages:

It does not indicate the site of the lesion.

HEARING TEST:

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Determines the cause of damage to the nerve has involved the hearing nerve, inner ear, or delicate hearing mechanism.

BALANCE TEST:

Evaluates balance, nerve involvement.

TEAR TEST:

Measures the eye’s ability to produce tears.

X-RAY:

Shows the fractures.

IMAGING:

CT (computerized tomography) or MRI (magnetic resonance imaging) determines if there is infection, tumor, bone fracture or other abnormalities in the area of the facial nerve.

NERVE CONDUCTION TEST:

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Stimulates the facial nerve to assess how badly the nerve is damaged. This test may have to be repeated at frequent intervals to see if the disease is progressing.

LABORATORY STUDIES (BLOOD STUDIES):

It may be necessary to determine the underlying cause like auto immune problems, Lyme disease or other viral infections which can lead to Bell’s palsy.

DIFFERENTIAL DIAGNOSIS

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Ramsey hunt syndrome:

1. It is similar to Bell’s palsy unlike Bell’s palsy, the virus that cause Ramsey hunt syndrome has been conclusively identified. It is Varicella zoster virus.

2. The first symptom is usually severe pain. There may be fever, headache and localized tenderness.

3. In addition to classic symptom of bell’s palsy Ramsey hunt syndrome is associated with some additional symptoms that help to differentiate.

Pain:

Bell’s palsy patients may complain of pain often in or behind the ear which can be acute. However, it will tend to face with in a week or two. The pain associated with Ramsey hunt syndrome is often more severe, and more likely to be felt inside the ear. It may start before muscle weakness is apparent, and may last for weeks or months, some times longer.

Vertigo:

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Dizziness is occasionally reported by bell’s palsy patient, but often associated with Ramsey hunt syndrome. It can be more severe and long lasting.

Hearing loss:

Ramsey hunt syndrome can also affect the auditory nerve, resulting in hearing deficit. This should not occur with bell’s palsy is an important to diagnose for physician.

Blisters:

The primary symptom that makes a diagnosis of Ramsey hunt syndrome likely is the appearance of blisters in ear. The blisters can appear prior to, concurrent to, or after the onset of facial paralysis. They can be expected last 2-5 weeks, and can be quite painful. The pain can continue after the blisters have disappeared. Swollen and tender lymphnodes near the affected area.

Hemifacial spasm:

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Hemifacial (vs) Bell’s palsy

1. Synchronous contraction of all muscles innervated by the facial nerve

2. Facial nerve in the hemi facial spasm is irritated at the facial nerve root or facial nerve nucleus.

3. The etiology remains unknown.4. Onset usually occurs in middle to old age and women are

preferentially affected.

Bell’s palsy: Synkinesis

1. Involuntary movement of muscles with volitional movements.

2. The facial nerve in the Bell’s palsy is by the compression or partial cut.

3. Complete cut of the facial nerve at the stylomastoid foramen.

4. The etiology is by the trauma infections of ear, tooth extracts, inflammations, exposure to the cold weather.

5. This is common condition, affecting all ages and both sexes.

Facial palsy (vs) Bell’s palsy:

1. The patient ability to wrinkle the forehead is impaired in a lower motor neuron (bell’s palsy) but, it is not impaired in upper motor neuron lesion(facial palsy)

2. In the presence of LMN lesion, the eye can be rolling up as an ineffectual to shut the eyelids is made.

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3. In an UML lesion very slight weakness of eye closure is usually detectable as an inability to bury the eyelashes completely on the affected side.

4. In a LMN lesion profound asymmetry is obvious. In an UMN lesion slow and incomplete movement of the mouth, on the opposite the casual lesion may be noted.

DIAGNOSIS

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BELL’S PHENOMENON:

Lateral and upward movement of eye ball and deviation of mouth to opposite side.

TREATMENT

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Medical treatment:

Medication that may help to the compression. They should be started as quickly as possible. There is no proven medical treatment, through a course of

steroids such as PREDNISOLONE 40-60 mg daily for a week may speed recovery.

Medications are started from the 7days on set of Bell’s palsy.

Prednisolone may be prescribed later if it appears the inflammation has not subsided.

Steroids are “safe and probably” effective in improving facial functional outcomes in patients with bell’s palsy results show significantly better out comes with steroids, however, they do not final any difference in the time frame for recovery.

Antivirals:

Acyclovir combined with prednisone is more effective in improving facial functional out comes in patients with Bell’s palsy.

The most important part of treatment is to keep the eyes healthy and moist. One of the purposes of blinking and closing the eyes is to keep the eyes wet. If a person can’t close their eyes, because the muscles that control the eyelids are paralyzed, it is important to keep the eyes moist and prevent itching. Eye drops are prescribed for the day and an eye ointment for the night to prevent drying of the surface of the eye cornea. Diminished blink and the absence of tearing together can reduce or eliminate the flow of tears across the eyeball, resulting in the drying, erosion, and ulcer formation on the cornea and possible loss of the

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eye. Closing the eye with finger is an effective way of keeping the eye moist. Use the back of the finger to ensure that the eye is not injured with the finger tip. Protective glasses or clear eye patches are often used to keep the eye moist, and to keep foreign materials from entering the eye.

Rest is important. Wear glasses with tented lenses or sunglasses. Facial electrical muscle stimulation Facial exercises Rehabilitation

Surgical management:

Decompression of the facial nerve can be accomplished by micro surgical procedure.

For Bell’s palsy it remains controversial, even when nerve degeneration is severe.

Complications:

1) Hearing loss

2) Facial nerve damage

Prognosis:

The prognosis for Bell’s palsy is generally very good. With or without treatment, most patients begin to get significantly better with in 2 weeks, and about 80 percent recover completely with 3

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months. For some, however, the symptoms may last longer. In a few cases, the symptoms may nerve completely disappear. Only in 10 patients nerve experience a complete disappearance of symptoms. The extent of nerve damage determines the extent of recovery. There is no specific treatment for Bell’s palsy.

ASSESSMENT

Subjective assessment:

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Name :

Age :

Occupation :

Chief complaints :

History:

Present history :

Past history :

Personal history : Alcoholic

Smoke

Medical history : Diabetes

Hypertension

Socio-economic history : Poor

Middle class

High class

Objective assessment:

On observation: Facial expression

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Bell’s phenomenon

Position of eye ball

Mouth deviation

Skin appearance

Swelling

On palpation : Tenderness

Warmth

On Examination:

1) Motor examination

a) Manual muscle testing: Orbicularis oris

Mentalis

Orbicularis occuli

Muscles of mastication

Muscles of tongue etc.

2) Sensory examination: Gustatory sense

3) Reflexes: Strength duration curve (type of lesion)

Nerve conduction velocity test (site of lesion)

X-ray (fractures),

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C.T.scan, M R I (tumours)

Differential diagnosis : Ramsey hunt syndrome,

Pain,

Vertigo

Hearing loss,

Hemifacial spasm

Provisional diagnosis:

Problem list :

Means :

Physiotherapy management:

Home programme :

PHYSIOTHERAPY MANAGEMENT

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Physiotherapy plays an important role in treating the patient with Bell’s palsy by means of electrical stimulation, facial massage, facial exercises and home advices.

Electrical stimulation:

Electrical stimulation is given to the patient with Bell’s palsy in order to maintain the muscle properties of facial muscles.

It is done by using galvanic and faradic currents.

Galvanic current:

Facial muscles are stimulated by galvanic current which is a unidirectional current of unvarying intensity and has less refractory period with 300-600 milli second’s duration, rectangular impulse, 10Hz of frequency, which will give brisk contraction.

Uses:

With the galvanic current occurs, so that the waste products are removed and increased blood supply, along with nutrients.

With the cathodial galvanism, counter irritation takes place & pain is relieved.

In Bell’s palsy cathodal galvanism is used with large anode and small cathode. Here active electrode is cathode (pen electrode) inactive electrode is anode (plate electrode).

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Active pen electrode is small 2milli ampere per square inch.

Facial muscles are situated superficially and they are very small. So the resistance of the underlying tissue is much less than that of the skin. Hence , the current spreads considerably once it has passed through the skin, so therefore the effects are much greater in the superficial than in the deep tissues, because of this galvanic current is used for stimulation of the facial muscles and it also has small refractory period.

Impulse- Rectangular Duration- 100 milli seconds Intensity- Vary according to duration and regeneration of

the nerve and individual tolerance.Placement of electrodes:

Inactive plate electrode is placed over the nape of the neck.

Active pen electrode is used for stimulating the muscles by keeping the pen electrode over the motor points of facial muscles.

Faradic current:

Nerve branches are stimulated by the faradic current which is having frequency of 50 cycles/seconds and 1milli second duration.

With surged faradism, gives contraction of the corresponding muscles similar to a voluntary contraction.

Surged faradism is mainly given at three areas

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1. Lower branch is stimulated at the angle of jaw.

2. Middle branch is stimulated in front of the ear.

3. Upper branch is stimulated at the corner angle of the eye.

Duration-100 milli seconds Intensity-Vary according to duration and regeneration of

the nerve and individual tolerance.Placement of electrodes:

Inactive plate electrode is placed over the nape of the neck

Active pen electrode is used for stimulating the nerve trunks by keeping the pen electrode over them.

MASSAGE:

Massage should be performed to the patient in order to improve circulation, venous & lymphatic flow.

Stroking:

Performed in an upward, outward direction.

Effect:

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Stroking stimulates the cutaneous touch receptors, stimulates the peripheral nerves.

Effleurage:

It is the movement of the palmar surface of the hand over the external surface of the body with constant moderate pressure in the direction of venous and lymphatic flow.

Essential features:

Contact and continuity should be maintained throughout the technique.

Effects and uses:

It facilitates the circulation in the capillaries. Increase arterial circulation, which increases the nutrition

of the part, tone of the muscle is improved.

Finger pad kneading:

Interphalangeal joint of thumb is flexed and constant pressure is applied.

Thumb tip kneading improves circulation of the muscles and its nutrition is increased over the facial muscles, given in cases Bell’s palsy, myofacial pain, facial palsy.

It is given at the eye brows, over the eyelids, angles of the nose & around the mouth.

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Hacking:

Reversal of hacking is given over the muscular areas. Alternate supination and pronation of the forearm

combined with ulnar and radial deviation of the wrist and palmar surface of the medial border of medial three fingers will come and contact with the skin, these movements will produce hacking.

41

Hacking is given to stimulate and warm up a part generally.

These techniques applied for 5minutes or so daily help to maintain lymphatic and blood flow to prevent contractures.

VIBRATIONS:

Constant touch of the therapist finger with the patient skin and application of rapid intermittent pressure with out changing position of hand.

Technique:

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Co-contraction of the upper extremity, there is osciallatory movement of hand in up ward and down ward direction and transmits the mechanical energy.

It is perfomed on the stylomastoid foramen.

Exercises:

Exercises are taught to the patient to increase the muscle power.

1. Look surprised then frown.2. Squeeze eyes closed then open wide.3. Smile, grin say ‘O’4. Say A E I O U5. Hold straw in mouth then suck and blow whistle.6. Puffing of air in mouth7. Chewing bubble gum.

Adhesive plaster:

Pull the deviated side of the mouth to affected side.

It is applied on the affected side of the face in form of inverted ‘Y’ shape.

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Application:

One strap applied from the lateral angle of the eye towards the ear, another is applied from the lateral angle of the mouth towards the ear maintaining a fold on cheek.

Adhesive plaster is also applied parallelly pulling the deviated side towards the affected side.

Resisted Exercises:

Manual resistence: The thumb or index finger is placed lightly over the opened eyelid above the lashes, and resistance is given in a downward direction (to close the eye.)

Instruction to patients:

Open your eyes wide, hold it, don’t let me close them.

Orbicularis Occuli:

Manual resistance:

Place the thumb and index finger below and above (respectively) each closed eye using a light touch. The examiner

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attempts to open the eyelids by spreading the thumb and index finger apart.

Instruction to patient:

Close your eyes as tightly as you can hold them closed. Don’t let them open them or close your eye against my finger.

Corrugator supercilii:

Manual resistance: The examiner uses the thumb (or index fingers) of each hand placed gently at the nasal end of each eyebrow and attempts to move the eyebrows apart (somoothers away the frown)

Instruction to the patient:

Frown. Don’t let me erase it,

Occipitofrontalis:

Manual resistance:

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Examiner places the pad of a thumb above each eyebrow and applies resistance in a downward direction (smoothing the forehead).


Raise your eyebrow as high as your can. Don’t let me pull them down.

Procerus:

Manual resistence:

The pads of the thumbs are placed beside the bridge of the nose, and resistence is given laterally (smoothing the creases)

Obicularis oris:

Manual resistence:

A tongue blade rather than a finger is uses to provide resistence in deference to hygiene. The blade is placed diagonally across both upper and lower lips, and resistence is applied in ward toward the oral cavity.


Purse your lips. Hold push against the tongue blade.

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Buccinator:

Manual resistence:

A tongue blade is uses for resistence. The blade is placed in side the mouth, its flat sidelying against the cheek. Resistence is given by levering the blade inward against the cheek (at the angle of the mouth), which will cause the flat blade to push the test cheek outward.

Alternatively, the gloved index fingers of the examiner may be used to offer resistance. In this case, the gloved index fingers are placed in mouth (the left finger to the inside of the patient’s left cheek and vice versa). The fingers are used simultaneously to try to push the cheeks outward. Use caution in this form of the test for patients with cognitive impairment (test they bite) or with those who have a bite reflex.


Suck in your cheeks. Hold doesn’t let me push them out.

Levator labii superior alaeque nasi:

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These two muscles elevate the upper lip. The labii superioris also protracts the upper lip, and the alaeque nasi dilates the nostrils.

Home programme:

Using mufflers Wearing goggles Avoid doing head bath frequently Pronouncing the letter A, E, I, O, U. Mirror exercises Clenching the teeth Compressing the nose,smiling Wearing adhesive plasters Look surprised then frown Hold straw in mouth,suck and blow Blowing of air in between the cheek Chewing a chewing gum These exercises are performed in lying then in sitting

position. The patient may assist at first then progress to resisting.A mirror is useful to enable the patient observe the muscle, it is not necessary for the patient to be seen by the physiotherapist very often, but monitoring visits should be arranged.

REHABILITATION

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“Face is the image of the soul” Facial palsy is a disability of communication as human

beings, our primary form of non-verbal communication relies upon minute changes in facial expression that reveal our innermost feelings.

Just as an aphasic person cannot communicate verbally after stroke, the patient with facial paralysis cannot convey the normal social signals of interpersonal communication.

Those who work with facial paralysis patients are actually aware of rehabilitation both the physiological and psychological aspects of this disability.

Restoring function and expression to the highest level possible results in improved health, self esteem, self acceptance by others, and quality of life.

Neuromuscular retraining is gaining recognition as an element for optional recovery form facial nerve paralysis retraining techniques have developed for treating sequelae that range from flaccidity to mass action and synkinesis, improving facial motor control and enhancing patient satisfaction and outcomes.

Physical, occupational and speech therapists trained specially in facial neuromuscular retraining provide an important element in the continuity on care for the patient with facial paralysis.

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Treatment begins with a through clinical evaluation. Realistic goals are established and a comprehensive, individualized home program is developed. This is accomplished through specific neuromuscular retraining techniques and augmented sensory feed back, including surface electromyography with in an educational model.

CASE I


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Name : L.Aruna Kumari

Age : 48 Years,

Gender : Female,

Occupation : House Wife,

Chief complaints : a) Mouth is deviated to left side,

: b) Unable to chew food properly,

: c) Unable to close right eye,

: d) Food particles stay in between the teeth and cheek.

History:

Present history : Her mouth is deviated to left side and she is also unable to chew food properly. She cannot close her right eye. Food particle stay in between teeth and cheek on right side.

Past history : When she exposed to cold air her mouth is deviated to left side. At that time she had pain in the ear. She was unable to close her right eye and unable to speak. She was also under medications.

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Personal history : No relevant factors

Medical history : She is not diabetic, but known.

Hypertension

Socio-economic history : Middle class



Frowning is difficult on right side, bells phenomenon is positive on right side. Mouth deviation is present towards left. Position of eye ball is lateral on right side, skin is pale, swelling on right side.

On palpation : Tenderness is present at ear, warmth is absent.

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On Examination:


a) Manual muscle testing: Mentalis

Orbicularis occuli,

Orbicularis oris,

Muscles of mastication, etc.

Are unable to do the action.

2) Sensory examination: Gustatory sense is metallic.

3) Reflexes: Naso lacrimal reflex is absent.

Palmomental reflex is absent.

Corneal reflex is absent.

Investigation : S D curve shows denervation. Blood reports are normal.

X ray shows no fracture

Provisional diagnosis : Right side Bell’s palsy.

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Problem list : 1) Unable to close right eye properly.

2) Speech is difficult

3) Eating, Chewing is difficult.

4) Mouth deviated to left side.

Means & Treatment :

1) Counseling, Explaining the course, features and prognosis of the disease.



GALVONIC CURRENT: Duration – 100 milliseconds,

Intensity – Vary according to duration and regeneration of the nerve and individual tolerance.

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FARADIC CURRENT: Duration – 0.1 to 0.3 milliseconds,


2) Facial massage.

3) Adhesive plaster.

4) Exercises: Whistling.

Hold straw in mouth, then suck and blow air or water.

Pronounce vowels A E I O U

Home Programme:

Use muffler and cotton in the ear Wearing goggles Avoid head bath for 15 days Pronouncing the letter A E I O U

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Mirror exercises like showing the teeth Compressing the nose, smiling Look surprised then frown Hold straw in mouth, suck and blow Blowing of air in between the cheek. Chewing bubble gum These exercises are performed in lying at first then sitting.

The therapist may assist at first then progress to resisting. A mirror is useful to enable the patient observe the muscle. It is not necessary for the patient to be seen by the physiotherapist very often, but monitoring visits should be arranged.

CASE II


Name : G.Rama Devi.

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Age : 31Years,

Gender : Female,

Occupation : Clerk,

Chief complaints : a) Mouth is deviated to right side,


: c) Unable to close Left eye,


History:

Present history : Her mouth is deviated to right side and she is also unable to chew food properly. She cannot close her left eye. Food particle stay in between teeth and cheek on left side. Pain on left side of the face.

Past history : One Year back during pregnancy period she had an attack that leads to mouth deviation and again she had an 2nd attack of same problem, she had under gone medications and also physiotherapy, she unable to speak and close her left eye.

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Medical history : She is not diabetic, and no history of hypertension.




Frowning is difficult on left side, bells phenomenon is positive on left side. Mouth deviation is present towards right. Position of eye ball is lateral on left side, skin is pale, swelling on left side.


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On Examination:



Orbicularis occuli,

Orbicularis oris,









Provisional diagnosis : Left side Bell’s palsy.

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Problem list : 1) Unable to close left eye properly.



4) Mouth deviated to right side.

Means & Treatment :







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2) Facial massage.





Home Programme:

Use muffler and cotton in the ear Wearing goggles Avoid head bath for 15 days Pronouncing the letter A E I O U Mirror exercises like showing the teeth Compressing the nose, smiling

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Look surprised then frown Hold straw in mouth, suck and blow Blowing of air in between the cheek. Chewing bubble gum These exercises are performed in lying at first then sitting.

The therapist may assist at first then progress to resisting. A mirror is useful to enable the patient observe the muscle. It is not necessary for the patient to be seen by the physiotherapist very often, but monitoring visits should be arranged.

CASE III


Name : B.Nimisha,

Age : 17 Years,

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Gender : Female,

Occupation : Student,

Chief complaints : a) Mouth is deviated to right side,


: c) Unable to close left eye,


History:

Present history : Her mouth is deviated to right side and she is also unable to chew food properly. She cannot close her left eye. Food particle stay in between teeth and cheek on left side.

Past history : When she exposed to cold air her mouth is deviated to right side. At that time she had pain in the ear. She was unable to close her left eye and unable to speak. She also had a history of previous history of attack of ear infection. She was also under medications.

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Medical history : She is not diabetic, and no history of

Hypertension




Frowning is difficult on left side, bells phenomenon is positive on left side. Mouth deviation is present towards right. Position of eye ball is lateral on left side, skin is pale, swelling on left side.


On Examination:

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Orbicularis occuli,

Orbicularis oris,









Provisional diagnosis : Left side Bell’s palsy.

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Problem list : 1) Unable to close left eye properly.



4) Mouth deviated to right side.

Means & Treatment :








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2) Facial massage.





Home Programme:

Use muffler and cotton in the ear Wearing goggles Avoid head bath for 15 days Pronouncing the letter A E I O U Mirror exercises like showing the teeth Compressing the nose, smiling Look surprised then frown Hold straw in mouth, suck and blow Blowing of air in between the cheek. Chewing bubble gum

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These exercises are performed in lying at first then sitting. The therapist may assist at first then progress to resisting. A mirror is useful to enable the patient observe the muscle. It is not necessary for the patient to be seen by the physiotherapist very often, but monitoring visits should be arranged.

CONCLUSION

Based on these cases it has been concluded that systemic

evaluation 1 assessment with physiotherapy assistance following

any activity given an solute improvement considered with

FACIAL PALSY.

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It has been observed and examined that FACIAL

MUSCLES has improved.

Practically it was found that the patients satisfied with

PHYSIOTHERAPY PROCEDURES and TREATMENT and

also improved strength and functional activities.

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Bell

Documents

food particles

food particle

ramsey hunt

chew food

naso lacrimal

chewing bubble

mentalis orbicularis

facial expression