BELL PALSY IDIOPATHIC FACIAL MONONEUROPATHY Ashley Heatley NURS870

WHAT IS BELL PALSY?  ABRUPT PARALYSIS OF THE 7 TH CRANIAL NERVE  RESULT OF DAMAGE OR TRAUMA TO THE FACIAL NERVE THAT CAUSES SWELLING, INFLAMMATION OR COMPRESSION  APPROXIMATELY 40,000 AMERICANS PER YEAR  MOST COMMON AGES  EQUAL IN MALES:FEMALES  80% OF ALL FACIAL MONONEUROPATHIES ARE BELL PALSY  THIS IS THE MOST COMMON CAUSE OF FACIAL PARALYSIS  ANATOMY REVIEW  7 TH CRANIAL NERVE EXITS THE SKULL THROUGH THE FALLOPIAN CANAL, A NARROW CANAL JUST BENEATH THE EAR TO INNERVATE THE MUSCLES OF THE FACE  EACH FACIAL NERVE IS RESPONSIBLE FOR ONE SIDE OF THE FACE  MUSLCES INNERVATED BY THE FACIAL NERVE ARE THOSE FOR BLINKING AND CLOSING THE EYE AS WELL AS SMILING AND FROWNING  ALSO INNERVATED ARE THE TEAR GLANDS, SALIVA GLANDS, AND THE STAPES IN THE MIDDLE EAR  FACIAL NERVE TRANSMITS TASTE SENSATION FROM THE TONGUE

SIR CHARLES BELL

WHAT CAUSES BELL PALSY?  EXACT CAUSE IS UNKNOWN  MANY BELIEVE A VIRAL INFECTION (SUCH AS HERPES VIRUS) CAUSES FACIAL NERVE SWELLING AND INFLAMMATION SECONADRY TO THE INFECTION  THIS SWELLING CAUSES PRESSURE ON THE NERVE AS IT PASSES THROUGH THE FALLOPIAN CANAL WHICH LEADS TO ISCHEMIA  IN MILD CASES AND RECOVERY IS QUICK, THE DAMAGE WAS ONLY TO THE MYELIN SHEATH AND THE NERVE ITSELF WAS PROTECTED

PRESENTATION TYPICALLY UNILATERAL. RANGES FROM MILD WEAKNESS TO TOTAL PARALYSIS.SYMPTOMS USUALLY OCCUR SUDDENLY AND PEAK WITHIN A FEW HOURS AND UP TO 48 HOURS.  TWITCHING  WEAKNESS  PARALYSIS  EYELID DROOPING  DRYNESS OF THE EYE  EXCESSIVE TEARING OF THE EYE  HEADACHE  DIZZINESS  FACIAL DROOP  DROOLING  JAW DISCOMFORT  IMPAIRMENT OF TASTE  DIFFICULTY EATING OR DRINKING  IMPAIRED SPEECH  TINNITUS  HYPERSENSITIVITY TO SOUND  POSTAURICULAR PAIN

OBJECTIVE DATA COLLECTION PURPOSE IS TO SEARCH FOR AN UNDERLYING CAUSE REVIEW OF SYSTEMSPAST MEDICAL HISTORY  FACIAL TRAUMA  SKULL FRACTURE?  FACIAL INJURY?  EAR INFECTION  HERPES ZOSTER  TICK BITE  INFLUENZA (OR RECENT INTRANASAL VACCINATION)  DIABETES  HYPERTENSION  HYPOTHYROIDISM  PREGNANCY  LYMES DISEASE  MALIGNANCY  HEAD OR NECK  SARCOIDOSIS  SJOGREN SYNDROME  AMYLOIDOSIS  GUILLAIN-BARRE

PHYSICAL EXAM  COMPLETE NEUROLOGICAL EXAM  INCLUDE OCULAR, OTOLOGIC, AND ORAL EXAMS  ASSESS FOR ANY ADDITIONAL DEFICITS  ASSESS FOR ZOSTERIFORM LESIONS OF SHINGLES  FOLLOW INNERVATION OF CRANIAL NERVE AND ASSESS AUDITORY CANAL, TM, AND POSTAURICULAR AREA IN ADDITION TO THE FACE.  ALSO ASSESS TM FOR ANY OTHER ABNORMALIITES SUCH AS CHOLESTEATOMA OR OTITIS MEDIA  EXAM SKIN FOR ERYTHEMATOUS LESION OF LYMES  PALPATE LYMPH NODES AND PAROTID GLAND

EXAM FINDINGS

DIAGNOSTIC TESTS  TYPICALLY A DIAGNOSIS OF CLINICAL EXAM  NO SPECIFIC TEST FINDINGS TO CONFIRM DIAGNOSIS  ELISA FOR LYME FOR R/O PURPOSES  CBC FOR PRESENCE OF INFECTION  HGB A1C FOR DIABETES  THYROID FUNCTION  MRI FOR SUSPICION OF INTRACRANIAL CAUSE  ELECTROMYOGRAPHY (EMG) CAN BE DONE TO HELP PREDICT RECOVERY BY ASSESSING NERVE DAMAGE AND ITS SEVERITY  THREE WEEKS FROM ONSET OF SYMPTOMS MUST PASS BEFORE EMG CAN BE DONE DIAGNOSTICALLY

DIFFERENTIAL DIAGNOSIS  VARICELLA-ZOSTER  SJOGREN SYNDROME  SARCOIDOSIS  ACOUSTIC NEUROMA  MIDDLE EAR DISEASE RED FLAGS  TUMOR/NEOPLASM  LYME’S DISEASE  TIA  CVA

TREATMENT  IF A UNDERLYING CAUSE IS IDENTIFIED (1/3 OF CASES), TREATMENT IS DIRECTRED TOWARDS THAT PATHOLOGY.  FOR IDIOPATHIC DIEASE (2/3 OF CASES) TREATMENT IS LARGELY SUPPORTIVE AS MOST WILL EXPERIENCE A SELF LIMITED COURSE.  FOR PREVENTION OF CORNEL INJURY  METHYLCELLULOSE DROPS (LACRI-LUBE) BID AND QHS  TAPING OF EYE AT BEDTIME  EDUCATION  IMPORTANCE OF MAINTAINING CORNEAL HYDRATION AND PROVIDING PROTECTION  DISEASE PROCESS AND PROGNOSIS

TREATMENT  CORTICOSTEROIDS  DO NOT USE WITH LYME’S DISEASE!!!  BEST IF STARTED WITHIN 72HOURS OF SYMPTOMS  PREDNISONE 1MG/KG QAM X7-10DAYS THEN D/C  IF NO IMPROVEMENT, TAPER OVER ADDITIONAL 10DAYS  ANTIVRIAL THERAPY  CONSIDER ADDING WITHIN 72 HOURS IN ADDITION TO STEROIDS  ACYCOLVIR 400MG 5X/DAY 7-10DAYS  VALACYCLOVIR 500MG BID 7DAYS  FAMCICLOVIR 750MG TID 7DAYS  SURGICAL DECOMPRESSION  CONTROVERSAL  RISK OF PERMANENT NERVE PARALYSIS  MUST BE PERFORMED WITHIN 14 DAYS OF SYMPTOMS

OUTCOMES  PROGNOSIS IS GENERALLY VERY GOOD  MAJORITY OF PATIENTS HAVE A FULL RECOVERY (75-85%)  EXTENT OF NERVE DAMAGE DETERMINES EXTENT OF RECOVERY  EVEN THOSE WITH A LESS FAVORABLE PROGNOSIS HAVE A GOOD CHANCE (85%) OF FULL RECOVERY WITH TREATMENT  MOST PATIENTS BEGIN TO IMPROVE WITHIN 2 WEEKS  WITH OR WITHOUT TREATMENT  SYMPTOMS MAY LAST LONGER  MAJORITY RECOVERY COMPLETELY WITHIN 3-6MONTHS  IN A FEW CASES THE SYMOTOMS NEVER COMPLETELY RESOLVE

REFERENCES  Baugh, R.F., Basura, G.J., Ishil, L.E., Schwartz, S.R., Drumheller, C.M., Burkholder, R., … Vaughan, W. (2013). Clinical practice guideline: Bell’s Palsy. Otolarynogeal Head and Neck Surgery, S1-S27. doi  Boss, B.J. and Huether, S.E. (2014). Alterations in cognitive systems, cerebral hemodynamics, and motor function. In McCance, K.L. & Huether, S.E. (Eds.), PathophysiologyL The Biologic Basis for Disease in Adults and Children ( ). St. Louis, MO.  Cash, J.C. (2014). Bell’s Palsy. In Cash, J.C. & Glass, C.A. (Eds.), Family Practice Guidelines ( ). New York, NY.  National Institutes of Neurological Disorders and Stroke. (2016). Bell’s Palsy Fact Sheet. Retrieved from detail_bells.htm  Pruitt, A.A. (2014). Approach to the patient with Bell Palsy (Idiopathic facial neuropathy). In Goroll, A.H. & Mulley, A.G. (Eds.), Primary care medicine: Office evaluation and management of the adult patient ( ). Philadelphia, PA.  Taylor, D.C.(2015). Bell Palsy. Retrieved from emedicine.medscape.com/article/ overview

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