Sunrise teaching Elaine McKinley.

Slides:



Advertisements
Similar presentations
Otitis Media Lawrence Pike.
Advertisements

Sore Throat (acute) Lawrence Pike.
Idham Hafize Supi Nurmarzura Abdul Latif
Gross Anatomy: Cranial Nerve Review Ref: Table 8.5 (pages ) in Drake et al.
1 Facial Palsy BANDAR AL-QAHTANI, M.D. KSMC. 2 Etiology Past theories: vascular vs. viral McCormick (1972) – herpes simplex virus Murakami (1996) 11/14.
Bells Palsy. Aetiology Most cases unknown Most likely cause is viral.
Persons with Neurological Defects Special Needs. Bells Palsy Facial nerve paralysis Damage to the facial nerve may cause imbalance of the face at rest.
Clinical skills lab. Facial nerve examination Sunday
-George Kresovich -Justin Goodridge
Imaging in Acute Facial Nerve Paralysis
Anatomy: Intracranial Intratemporal Intrameatal Labyrinthin Tympanic Mastoid Extracranial.
Evaluation and management of Bell’s palsy Chunfu Dai Otolaryngology Department Fudan University.
Bell’s Palsy, Muscular Dystrophies -Erb’s Palsy Victor Politi, M.D., FACP Medical Director, SVCMC, School of Allied Health Professions, Physician Assistant.
The Face and Facial Expression
بسم الله الرحمن الرحيم.
Cranial Nerves.
Case Presentation by Michael Armstrong.
BELL’S PALSY Internal Medicine By Svetlana Gorbounov PA-S April, 2006.
Bell’s Palsy January 20,2010. History -Sir Charles Bell, Scottish Surgeon - First described in early 1800s based on trauma to facial nerves -Definition.
By: Whitley Morris and Brandi Hall. If so, contact your doctor immediately. You may have herpes zoster. Also known as shingles.
BELL’S PALSY BY: RANDY BONNELL BELL’S PALSY BY: RANDY BONNELL.
Neurolgy Chapter of IAP
Bell's Palsy By Jabar Boykin 03/6/13 Psychology(Hon)
THE FACIAL NERVE DR. SAMI ALHARETHY ASSIS. PROF. CONSULTANT-KSU
بسم الله الرحمن الرحيم THE FACIAL NERVE SAMI ALHARETHY.
Dr. amal Alkhotani Frcpc neurology, epilepsy
Ears! Mark Hambly.
Applied Neurological Injuries
H1N1 General Information Update Karen Dahl, MD Pediatric Infectious Diseases.
Anatomy & Physiology Diseases. Cerebral Palsy Disturbance in voluntary muscle action Caused by brain damage (birth injury, infections) S&S = exaggerated.
7th Cranial Nerve (Facial Nerve)
Dr Jennifer Price VTS ST2 1 st May  Otitis media with effusion (OME), also known as 'glue ear', is a condition characterized by a collection of.
Central Nervous System Disorders Peripheral Nervous System Disorders Sensory Disorders.
What is Otolaryngology  A medical and surgical subspecialty  Expert care of disorders of the Ear, Nose, Throat, Head and Neck  Attention to form and.
Facial nerve disorders
Moebius Syndrome is a rare disorder characterized by lifetime facial paralysis. People with Moebius Syndrome can’t smile or frown, and they often can’t.
A 40 year old female is complaining of attacks of lacrimation and watery nasal discharge accompanied by sneezing. She had a severe attack one spring morning.
Mixed cranial nerves.
Examples of Viruses. Influenza Seasonal Influenza: Flu Basics Influenza (the flu) is contagious respiratory disorder. It can cause mild to severe illness,
Severe acute respiratory syndrome. SARS. SARS is a communicable viral disease caused by a new strain of coronavirus. The most common symptoms in patient.
Anatomy & Physiology Diseases.
Cervical Instability.
The Cranial Nerves: A Review Dr. Ann Gathers Department of Biological Sciences The University of Tennessee at Martin Health Science Teacher Education Symposium.
THE FACIAL NERVE SAMI ALHARETHY
Peripheral Neuropathy : describes disorders of peripheral nerves, including the dorsal or ventral nerve roots; dorsal root ganglia; brachial or lumbosacral.
بسم الله الرحمن الرحيم.
DIAGNOSTICS BELL’S PALSY. CLINICAL: – Typical presentation – No risk factors or presenting symptoms for other causes of facial paralysis – Absence of.
Bell’s Palsy. THE FACIAL NERVE The facial nerve is a mixed nerve, as it contains motor, sensory and autonomic fibres.
원더스 참고자료 두통. 1 차성 두통에 대한 자료 2 차성 두통에 대한 자료.
MUMPS INFECTION & TROPICAL MEDICINE DIVISION. Definition : Mumps is an acute contagious disease caused by a paramyxovirus that has predilection for glandular.
THE NERVOUS SYSTEM JOSE S. SANTIAGO M.D..
Cranial nerve palsy.
Efficacy of Early Treatment of Bell’s Palsy With Oral Acyclovir and Prednisolone Otology & Neurotology 24: , 2003, Nov Naohito Hato, Shuichi Matsumoto,
Bell’s Palsy By: Josh Lumpkin. Who is usually affected by disease.  Which is often accompanied by pain or general discomfort.  Or 40,000 people in the.
Summary of Function of Cranial Nerves Figure 13.5b.
Bell’s palsy Anne and Anna. Summary Bell’s palsy is a condition that partly or completely paralyzes the side of your face. The facial nerve carries signals.
BELL PALSY IDIOPATHIC FACIAL MONONEUROPATHY Ashley Heatley NURS870.
Sarah aljamaan Ghadir jwaid
Facial Nerve Palsy.
Dr. Saad Al Asiri FACIAL PAIN & HEADACHE MD, DLO, KSF, Rhino
Tumors in ear.
The Cranial Nerves: A Review
INFECTION AND INFLAMMATION
MoeBius Syndrome.
Summary of Function of Cranial Nerves
Cranial Nerve VII: Facial Nerve
Management and classification Dr.Ishara Maduka
Control of facial expressions
Presentation transcript:

Sunrise teaching Elaine McKinley

7 year old with unilateral lower motor neurone facial paralysis Problem: 7 year old with unilateral lower motor neurone facial paralysis

Facial Nerve Cranial Nerve VII Efferent and afferent fibres Motor: Controls muscles of facial expression and innervates Stapedius muscle Sensory: conveys taste of the anterior two-thirds of the tongue Parasympathetic: Salivary and lacrimal glands

Muscles of facial expression Function Occipitofrontalis Raises eyebrows, wrinkles forehead horizontally Corrugator Supercilii Wrinkles forehead vertically Orbicularis Oculi Closes eye Orbicularis Oris Draws lips together Zygomaticus Major Elevates angle of the mouth (laughing) Buccinator Permits smiling; blowing / pursing of the lips

History Onset Progression Duration Unilateral/Bilateral Associated symptoms Any hx of head trauma / surgery Immunisation hx (polio, rabies, tetanus & influenza) Recurrence PMHx

Symptoms Change in the appearance of the face Difficulty closing one eye Difficulty making expressions, grimacing Difficulty with fine movements of the face Facial droop Difficulty eating (items fall out of the weak corner of the mouth) Face feels pulled to one side Face feels stiff Headache Impairment of taste Pain behind the ear Increased loudness of sound in one ear / Sensitivity to sound (hyperacusis)

Examination General systematic clinical examination Full neurological examination, including focused cranial nerve examination Examination of the neck must be performed to illicit a parotid neoplasm or cervical lymphadenopathy

Cranial Nerves I - VI

Cranial Nerves VII - XII

Signs of Facial Nerve Paralysis Facial asymmetry Eyebrow droop Inability to wrinkle forehead Drooping of corner of mouth Inability to close eye and uncontrolled tearing Unable to put hold lips tightly together

House-Brackmann scoring of facial function

Causes of Facial Nerve Palsy Idiopathic Bell’s palsy (40-70%) Melkersson–Rosenthal syndrome (recurrent alternating facial palsy, furrowed tongue, faciolabial oedema)

Causes of Facial Nerve Palsy 2. Infection (13-36%) Otitis media Mumps Mastoiditis Infectious mononucleosis (glandular fever) Herpes zoster cephalicus (Ramsay–Hunt syndrome) Malaria Chickenpox Tuberculosis Encephalitis Lyme disease HIV Meningitis Poliomyelitis (type I)

Causes of Facial Nerve Palsy 3. Trauma (19-21%) Skull base fractures Facial injuries Penetrating trauma to middle ear Barotrauma (altitude paralysis/scuba diving)

Causes of Facial Nerve Palsy 4. Metabolic Diabetes mellitus Hypertension Acute porphyria

Causes of Facial Nerve Palsy 5. Neoplastic (2-3%) Cholesteatoma Leukaemia Haemophilia Fibrous dysplasia Parotid tumours Facial nerve tumour Cerebello-pontine angle tumours

Causes of Facial Nerve Palsy 6. Toxic Tetanus Diphtheria Thalidomide Carbon monoxide

Causes of Facial Nerve Palsy 7. Iatrogenic Postimmunisation Antitetanus serum Vaccine for rabies Parotid surgery Mastoid surgery Forceps delivery

Causes of Facial Nerve Palsy 8. Autoimmune syndrome Thrombotic thrombocytopaenic purpura Kawasaki disease Guillian barre/Miller–Fisher syndrome

Causes of Facial Nerve Palsy 9. Neurological Millard-Gubler syndrome (abducens palsy with contralateral haemiplegia due to lesion in the base of pons involving corticospinal tract) Opercular syndrome (cortical lesion in facial motor area)

Causes of Facial Nerve Palsy 10. Congenital (8-14%) Dystrophia myotonica Moebius syndrome (facial diplegia associated with other cranial nerve deficits)

Investigations Hearing test Consider MRI progressing > 3 weeks lack of improvement after 6 months recurrent facial palsy single facial segment involvement high suspicion of an underlying neurological disorder

In the absence of other causes in the history or examination – presumed diagnosis is Bell’s Palsy

Treatment Eye care Steroid +/- antiviral Surgical intervention Artificial tears Moisturising eye ointment at night Protective eye wear Steroid +/- antiviral Surgical intervention

Prognosis of Bell’s Palsy Good prognosis Most have recovery between 3 wks – 3mths If not recovering/progressively worse ? Underlying cause

Reviewing the evidence for treating Bell’s Palsy Michael McGowan

WARNING Trying to read everything on these slides will cause your brain to melt.

Where to search?

No guideline but there is a CKS

Bell's palsy is an acute, unilateral, idiopathic, facial nerve paralysis. The paralysis also affects the eyelids, causing an impairment of blinking. The cause of Bell's palsy remains unclear, but it has been associated with the herpes virus. The annual incidence of Bell's palsy in the UK is 1 in 5000 people. It occurs most commonly between 15 and 60 years of age. When making a diagnosis of Bell’s palsy: It should be noted that maximum facial weakness develops within 2 days. Earache, pain behind the ear, aural fullness, or facial pain may precede the palsy. Severe pain might indicate Ramsay Hunt syndrome. This is caused by herpes zoster and is associated with a painful rash and herpetic vesicles. Confirmation that the paralysis is caused by a unilateral, lower motor neuron lesion is required. The muscles controlling facial expression are affected on one side of the face only. This may result in drooping of the brow and corner of the mouth, weakness of the frontalis (forehead muscle), or inability to close the eye. It should be confirmed that only the facial nerve is affected. Other features such as loss of taste of the anterior two-thirds of the tongue (on the same side as the facial weakness) may occur. Serious underlying pathology such as Lyme disease and parotid tumour should be excluded.

To manage Bell’s palsy: The person should be reassured that the prognosis is good: most people with Bell's palsy make a full recovery within 9 months. The person should be advised to keep the affected eye lubricated by using lubricating eye drops during the day and ointment at night. The eye should be taped closed at bedtime using microporous tape, if the ability to close the eye at night is impaired. For people presenting within 72 hours of the onset of symptoms, prescription of prednisolone should be considered. There are no data supporting the use of prednisolone in people presenting after 72 hours. Antiviral treatment is not recommended, either alone or in combination with prednisolone. If there is doubt regarding the diagnosis, or there is recurrent or bilateral Bell's palsy, an urgent referral to neurology or to an ear, nose, and throat (ENT) specialist should be arranged. If the cornea remains exposed after attempting to close the eyelid, an urgent referral to ophthalmology should be arranged.

If the paralysis shows no sign of improvement after one month, or there is suspicion of a serious underlying diagnosis (e.g. cholesteatoma, parotid tumour, malignant otitis externa), an urgent referral to ENT should be arranged. If there is residual paralysis after 6–9 months, referral to a plastic surgeon with a special interest in facial reconstructive surgery should be considered.

So where do these recommendations come from? To manage Bell’s palsy: The person should be reassured that the prognosis is good: most people with Bell's palsy make a full recovery within 9 months. The person should be advised to keep the affected eye lubricated by using lubricating eye drops during the day and ointment at night. The eye should be taped closed at bedtime using microporous tape, if the ability to close the eye at night is impaired. For people presenting within 72 hours of the onset of symptoms, prescription of prednisolone should be considered. There are no data supporting the use of prednisolone in people presenting after 72 hours. Antiviral treatment is not recommended, either alone or in combination with prednisolone. If there is doubt regarding the diagnosis, or there is recurrent or bilateral Bell's palsy, an urgent referral to neurology or to an ear, nose, and throat (ENT) specialist should be arranged. If the cornea remains exposed after attempting to close the eyelid, an urgent referral to ophthalmology should be arranged. So where do these recommendations come from?

Steroids are well known to work.

But what about using antivirals?

Read the abstract of this SR and talk about your conclusion

Significant

Not significant (just)

Steroids work Antivirals alone do not Might help in combination but there isn’t evidence to support this

Applying this evidence to children?

Applying this evidence to children? Open to all sorts of bias, no randomisation Mirrors the adult recommendations Small numbers Outcome more or less the same

Probably alright to do so

Summary Outcome is good Supportive treatment a must Improved by starting steroids within 72h Might be improved by using antivirals in combination Definitely not improved by using antivirals alone

And finally a point of interest… If the paralysis shows no sign of improvement after one month, or there is suspicion of a serious underlying diagnosis (e.g. cholesteatoma, parotid tumour, malignant otitis externa), an urgent referral to ENT should be arranged. If there is residual paralysis after 6–9 months, referral to a plastic surgeon with a special interest in facial reconstructive surgery should be considered. And finally a point of interest…

…In this guidline…

…were the evidence is appraised…

…Acupuncturists do better trials than ENT surgeons?

The End Questions for Elaine?