Bell's Palsy

                                                                  (Facial Paralysis)

                                                         I woke up with a broken face

It is named after Scottish surgeon Charles Bell  (1774–1842), who first described the connection of the facial nerve to the condition. Bell's palsy is the most common cause of one-sided facial nerve paralysis (70%) It occurs in 1 to 4 per 10,000 people per year. About 1.5% of people are affected at some point in their lives. It most commonly occurs in people between ages 15 and 60. Males and females are affected equally.

Bell's palsy is a condition that causes partial or total weakness or  paralysis of facial nerve. it may develop suddenly or develop more gradually over a period of time over 24-48 hours. It rarely occurs more than once. The rate increases with age. It affects approximately 1 person in 65 during a lifetime. Prognosis : Most recover completely. Fewer than 1 million cases per year in India are reported.Treatable by a medical professional. Requires a medical diagnosis. Lab test or imaging often required. Short term : resolves within days to weeks. Critical  needs emergency care.

Celebrities that have been diagnosed with Bell's palsy, the most common form of facial paralysis, include:

• Angelina Jolie. The actress was diagnosed with Bell's palsy in 2016 and opened up about her battle with facial paralysis. ...
• George Clooney. ...
• Pierce Brosnan. ...
• Sylvester Stallone. ...
• Katie Holmes.
• Anupam Kher an Indian actor

Introduction

Bell's palsy is most common cause of unilateral paralysis. Bell's palsy is a condition that causes a temporary weakness or paralysis of the muscles in the face. It  can occur when the nerve that controls your facial muscles becomes inflamed, swollen, or compressed. The condition causes one side of your face to droop or become stiff.

Bell's palsy symptoms results from injury to the facial nerve. This nerve supplies muscle function and sensation to the face affecting tears, taste, salivation and facial expression. 

Often signs of improvement begin within 14 days, with complete recovery within six months. A few may not recover completely or have a recurrence of symptoms.

Most people with Bell's palsy start to regain normal facial function within 3 weeks—even those who do not receive treatment.  Few recovery occurred 3–6 months later. Better prognosis for young patients, aged below 10 years old, while the patients over 61 years old presented a worse prognosis. Major possible complications of the condition are chronic loss of taste (ageusia), chronic facial spasm ,  facial pain and corneal infections. Another complication can occur in case of incomplete or erroneous regeneration of the damaged facial nerve. The nerve can be thought of as a bundle of smaller individual nerve connections that branch out to their proper destinations. During regrowth, nerves are generally able to track the original path to the right destination—but some nerves may sidetrack leading to a condition known as synkinesis  For instance, regrowth of nerves controlling muscles attached to the eye may sidetrack and also regrow connections reaching the muscles of the mouth. In this way, movement of one also affects the other. For example, when the person closes the eye, the corner of the mouth lifts involuntarily.

Causes

• Unknown .
• Edema, swelling and compression of the nerve in the narrow bone canal is responsible for nerve damage
• Cold is a precipitating factor.
• Upper respiratory tract infection
• When ever the resistance of the body is lowered
• Tumor of parotid gland
• Obesity
• Chronic blood pressure
• Viral infection.. Virus that has been linked to bell's palsy includes the virus that causes 

a . Cold sores and genital herpes (Herpes simplex)

b . Chickenpox and shingles (Herpes Zoster)

c . Mononucleosis (Epstein bar)

d . Cytomegalovirus infections

e . Respiratory illnesses (Adenovirus)

f . German Measles (Rubella)

g . Mumps (Mumps virus)

h . Flu (Influenza B)

i .  Hand-Foot-and- Mouth disease.(Coxsackie virus)

With Bell's Palsy, the nerve that controls your facial muscles, which passes through a narrow corridor of bone on its way to your face becomes inflamed and swollen and compressed, usually related to a viral infection. Besides facial muscles the nerve affects tears, saliva, taste and a small bone in the middle of the ear.

The facial nerve controls a number of functions, such as blinking and closing the eyes, smiling, frowning, lacrimation, salivation, flaring nostrils and raising eyebrows. It also carries taste  sensations from the anterior two-thirds of the tongue, through the chorda tympani nerve (a branch of the facial nerve). Because of this, people with Bell's palsy may present with loss of taste sensation  in the anterior ​²⁄₃ of the tongue on the affected side

Although the facial nerve innervates the stapedius muscle  of the middle ear  (through the tympanic branch), sound sensitivity,  causing normal sounds to be perceived as very loud (hyperacusis) , and dysacusis are possible but hardly ever clinically evident.

Although defined as a mononeuritis (involving only one nerve), people diagnosed with Bell's palsy may have "myriad neurological symptoms" including "facial tingling, moderate or severe headache/neck pain, memory problems, balance problems, paresthesias, ipsilateral limb weakness, and a sense of clumsiness" that are "unexplained by facial nerve dysfunction".

Around 9% of people have some sort of ongoing problems after Bell's palsy, typically the synkinesis already discussed, or spasm, contracture, tinnitus (ringing in the ear) or hearing loss during facial movement or crocodile-tear syndrome. This is also called gustatolacrimal reflex or  Bogorad's symdrome  and involves the sufferer shedding tears while eating. This is thought to be due to faulty regeneration  of the facial nerve, a branch of which controls the lacrimal and salivary glands. Gustatorial sweating can also occur.

peripheral and central facial palsy.

Signs and Symptoms

                                    

• Bell's palsy is characterized by a one-sided facial droop that comes on within 72 hours
• Facial weakness : 
• Inability to move the facial muscle
• Twitching of face
• Sudden weakness in the muscles on one half of the face.. 
• Headache

Mouth

• Drooling :  It is saliva flowing outside of your mouth unintentionally or dry mouth
• Difficulty speaking due to weakness around the mouth
• Inability to puff cheeks
• Asymmetrical smile
• Loss of naso-labial fold.
• Trouble speaking or forming words (dysarthria).
• Facial drooping in the corner of the mouth
• Inability to wrinkle brow as forehead is involved

Eye

• Drooping of eyelids.. 
• Inability to close eye lids
• Changes in the quality of tears produced

Ear

• Increased sensitivity to sound known as hyperacusis. 
• Pain in or behind the ear on the affected side
• Sensitivity to sound

Tongue

• Change of taste.
• Loss of the sense of taste

Jaw

• Pain around the jaw

Risk Factors

• Diabetes mellitus
• Stroke
• Recent upper respiratory tract infection
• Pregnancy
• Dysfunction of cranial nerve 7 (the facial nerve)
• Reactivation of an existing (dormant) viral infection has been suggested as a cause of acute Bell's palsy.Bell's palsy could be triggered by trauma, environmental factors, and metabolic or emotional disorders.

                            "Assesses the vital signs to rule out a stroke"

Diagnosis

• Diagnosis of Bell’s palsy will often involve your doctor observing your facial movements such as blinking your eyes, lifting your brow, smiling, and frowning, among other movements.
• Clinical : Classically a cranial nerve 7 palsy
• Cannot wrinkle
• MRI magnetic resonance imaging (MRI) for an individual with facial weakness or paralysis to rule out more serious conditions such as a tumor or stroke. 
• The degree of nerve damage can be assessed using Breckmann score. Brackmann score is a score to grade the degree of nerve damage in a facial nerve palsy. The measurement is determined by measuring the upwards (superior) movement of the mid-portion of the top of the eyebrow, and the outwards (lateral) movement of the angle of the mouth.

Consider

Cardio vascular accident (C.V. A)  cases reported of isolated cranial nerve 7 that is  (Facial nerve)  palsy with Pontine hemorrhage. Do a through neurological  exam as most C.V.A with facial droop have something else abnormal on neurological  examination.

Herpes Simplex / Herpes Zoster

Lyme disease . Treat if in endemic area.

                              "Its usually temporarily and resolves of its own."

Massage

Manual massage and exercises can help prevent this from occurring.

Facial Stimulation

1. Step 1: Begin by trying to move every part of your face slowly and gently.
2. Step 2: Use your fingers to gently lift your eyebrows. ...
3. Step 3: Using your fingers, gently massage the different parts of your face, including your forehead, nose, cheeks, and mouth.

Exercise

• Go in front of mirror and raise your eyebrows.
• Flare your nose, flare them down.
• Bring the eyebrows in together and push inwards.
• Just smiling, put the finger at the corner of your lips and help pull it up and then come down.

                            

Facial Yoga Exercises

1. Puff out the cheeks, push air into the mouth and move the air from one side to the other four times. Repeat up to 5 times a day to help raise the cheeks.
2. Make the eyes wide, raise the eyebrows and stick out the tongue. ...
3. Purse the mouth into a tight O
4. Clasp the hands to the face, and smile wide.
5. Go in front of mirror and raise your eyebrows.
6. Flare your nose, flare them down.
7. Bring the eyebrows in together and push inwards.
8. Just smiling, put the finger at the corner of your lips and help pull it up and then come down.

Heat

Using moist heat like MediBeads or even a warm washcloth several times a day can relieve pain and improve circulation. You can also prevent muscle waste, ease pain and maintain your facial tone by using electrical stimulation at home with a TENS unit.

Foods

Avoid hard, chewy foods as these can be difficult to prepare and choose a soft easy chew diet (such as pasta dishes, fish, well cooked meats and vegetables).

Treatment

How is Bell's palsy treated?

• Steroids to reduce inflammation.
• Antiviral medicine, such as acyclovir.
• Analgesics or moist heat to relieve pain.
• Physical therapy to stimulate the facial nerve.

Steroids have been shown to be effective at improving recovery in Bell's palsy while antivirals have not. In those who are unable to close their eyes, eye protective measures are required Management during pregnancy is similar to management in the non-pregnant.

Physical Therapy

Physiotherapy for facial paralysis works on the patient's muscles of the face, eyes, nose, lips, and other facial parts to promote facial movements effectively. And, the best part is that they can be performed within the comfort and privacy of your home

• Trying to make the biggest facial movement or muscle contraction that you can, such as smiling as much as you can
• Chewing gum with great force
• Blowing up a balloon with all of your effort to work the facial muscles

Anti Inflammatory

            "DON'T stop corticosteroids abruptly; they must be tapered."

Steroids

Course of steroid medication to reduce the swelling around the nerve that controls the movement of the face. In some cases, ..Corticosteroids  such as prednisone  improve recovery at 6 months and are thus recommended. Early treatment (within 3 days after the onset) is necessary for benefit,^.with a 14% greater probability of recovery

A 10-day course of corticosteroids (prednisolone 25 mg twice daily) started within 72 hours significantly improves the chances of complete recovery. There is no added benefit from acyclovir. Sullivan FM, Swan IR, Donnan PT, et al. Early treatment with prednisolone or acyclovir in Bell's palsy.

Antivirals

• Bell's palsy usually resolves on its own within six months. 
• Physiotherapy can help prevent muscles from permanently contracting.
• Corticosteroids : Prednisone 1 mg/kg body weight (maximum up to 60 mg) x 6 days. Followed by 10 day taper. Give Antacid along with it.
• Corticosteroids eye drops 
• Antiviral : Tab Acyclovir. When used with steroids, improves facial recovery.
• Supportive care : 
• Ocular lubricant : To prevent corneal abrasion.
• The eye should be protected from drying up with the use of eye  drops  or an eye patch.
• May need to tape eye shut.
• Otrivin ear drops
• Surgery is generally not recommended

Eye protection

Your eye care professional may also recommend artificial tears, ointments and gels to keep the affected eye moist, or an eye patch (with lubricating eye drops or an ointment) to keep the affected eye moist and covered overnight.

How to protect her eye from injury, and teaches to protect it from drying of the cornea.  Apply a soothing lotion (ointment) to the eye and places an eye patch over it. Or an eye drops to keep the eye moist throughout the day, 

When Bell's palsy affects the blink reflex and stops the eye from closing completely, frequent use of tear-like eye drops or eye ointments is recommended during the day and protecting the eyes with patches or taping them shut is recommended for sleep and rest periods. gentle exercise to perform daily to ease tension around the eye. The priority at this point is to protect the affected eye with exercise, ointment, drops, and the use of an eye patch.

                                     "Consult a physiotherapist".

Vitamin

Vitamin B 12 injections have been shown to be beneficial for people with Bell's palsy. Vitamin B12 deficiency can cause nerve degeneration, and both oral and injected vitamin B12 have been used to treat many types of nerve disorders.

Physiotherapy                                             

Physiotherapy  can be beneficial to some individuals with Bell's palsy as it helps to maintain muscle tone  of the affected facial muscle and stimulate the facial nerve It is important that muscle re-education exercises and soft tissue techniques be implemented prior to recovery in order to help prevent permanent contractures  of the paralyzed facial muscles. To reduce pain , heat can be applied to the affected side of the face. There is no high quality evidence to support the role of electrical stimulation for Bell's palsy.

exercises for her mouth, such as puckering, protruding her lower lip, and smiling with her mouth open and teeth exposed, in front of a mirror.

It improves the  ability to close the eye, smile, and close the mouth around a straw for drinking

Eating chewing gum.

Surgery

Surgery may be able to improve outcomes in facial nerve palsy that has not recovered. A number of different techniques exist. Smile surgery  or smile reconstruction is a surgical procedure that may restore the smile for people with facial nerve paralysis. It is unknown if early surgery is beneficial or harmful. Adverse effects include hearing loss which occurs in 3–15% of people.

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