Facial Palsy Bell’s Palsy

1. Loss of voluntary movement of the muscles of 1. The idiopathic paralysis of facial nerve of
one side of the face due to abnormal function of sudden onset.Unilateral motor neuron paralysis
the facial nerve is called Facial Palsy. of sudden onset, not related to any other
Disorders of facial Nerve diseases elsewhere in the body.
Central v/s Peripheral facial paralysis
UMN LESIONS LMN LESION 2. The characteristics varies from person to
a. Paralysis of inferior a. Paralysis of the person , comes on suddenly , mild to total
1/4 of the face. lateral half of the face paralysis with
Contralateral to the ipsilateral to the  Weakness , twitching on one of both sides
lesion. lesion.
of the face
b. Upper part of face b. The fibers carrying
 Facial and eyelid droop
is innervated LMN ( that are
 Drooling
bilaterally by the supplying the entire
UMN. lateral half of face)  Dryness of eye or mouth
c. Inferior half have are all within the  Impairment of taste
only contralateral fascial nerve.  Excessive tearing of eye
innervation. c. Seen in fascial  Patient feels stiffness of face pulled to one
d. Seen mostly in nerve lesions ( Bell’s side.
intracranial lesions Palsy )  Ipsilateral restriction of eye closure,
( stroke) difficulty with eating , fine facial movements
 Disturbance of taste - chorda tympani fibres

2. Facial Nerve Paralysis Signs: Bell’s Phenomenon - Normally on closing the

a. Facial asymmetry eye, the eyeball moves upwards and inwards.
b. Eyebrow droop This is on the affected side due to ineffective
c. Loss of forehead and nasolabial folds closure of the eyelids.
d. Drooping of corner of mouth
e. Uncontrolled tearing 3. Causes of Bell’s Palsy
f. Inability to close eye  Unknown cause -Evidence shows that
g. Lips cannot be held tightly together: difficulty reactivated herpes simplex virus (HSV) may
keeping food in mouth be involved in some cases.
h. Facial muscle atrophy  Reactivation of the HSV causes
inflammation, edema, ischemia, and
3. Causes of Facial Paralysis are : eventual demyelination of the facial nerve,
 Congenital - Mobius Syndrome ,Vascular causing pain and alterations in motor and
anomaly, Hemifacial microsomia , sensory function.
Goldenhar , Poland, Melkersson - Rosenthal  May be caused by a viral infection
 Birth- related = Traumatic or difficult 1. Viral Meningitis
delivery 2. Herpes Simplex
 Bell’s = Unknown cause,viral infection 3. Headaches
 Traumatic injury= Temporal bone fracture, 4. Chronic ear infections
Blunt force to cheek , Laceration, Swelling 5. High Blood Pressure
involving facial nerve 6. Diabetes
 Infections= Ear infection, Lyme disease, Viral 7. Sarcoidosis
infections (VZV ,Ramsay Hunt, HSV , EBV) , 8. Tumors
Mycoplasma ,Mastoiditis 9. Lyme Disease
 Neoplastic - Central , Parotid , or Acoustic 10. Trauma
tumors
 Iatrogenic- brain , middle ear and facial 4. Evaluation of Bell’s Palsy
surgery  Careful History - timing ,associated
 Ischemic- loss of blood supply to the nerve symptoms,recurrent,
of muscle  Physical examination
 Neurogenic - Gullian- Barre  CT/mri
 Hematologic - Leukemia ,Hemophilia  Electrophysiology
 Hypertension- High blood pressure Bell’s Palsy doesnt have any specific lab tests to
 confirm the diagnosis
4. Clinical Testing of Facial Nerve Functions Will exam for upper and lower facial weakness
 Observe patient’s face at rest and Electromyography-Confirms the presence of
movement for assymetry , facial spasm, damage and determine the severity
facial ticks and blinking MRI and CT - confirms the causes of pressure on
 Blink test- Delay in blinking on one side nerve.
 Testing facial movement 5. Treatment
 1. temporal branch = to wrinkle forehead, to  Controversial
elevate eye brow  Symptomatic
2. Zygomatic branch = to screw up the eye Protection of eye during the sleep - patch
3. Buccal branch = to wrinkle the nose Massage of the weakened muscles
4. Mandibular branch= to show the teeth , to Lubricating eye drops
blow out the cheeks  Prednisolone 60-80 mg/day in divided doses
5. Cervical branch= by grimacing Initial 4-5 days , then taper over next 7 to 10 days
.
House- Brackmann Grading system of facial Decrease the possibility of permanent paralysis
function From swelling of facial nerve in facial canal.
Grade Definition Degree of Decrease the severe pain
Injury
1 Normal Normal Medical Treatment
symmetrical Acyclovir 400 mg 5 times/day
function Famciclovir and valacyclovir 500 mg bid
2 Slight weakness Mild
and asymmetry dysfunction Surgical treatment
Complete closure Facial nerve decompression
of the eye with Indication
minimal effort Completely paralysis
.Barely notice Appropriate time for surgery is 2 to 3 weeks after
Synkinesis. Absent paralysis.
(Contructure or
spasm)

3 Obvious weakness Moderate

and asymmetry dysfunction`
Obvious synkinesis
, mass movement
or spasm. No
disfuguring

4 Obvious disfiguring Moderately

, weakness and severe
asymmetry .Severe dysfunction
synkinesis , mass
movement , spasm

5 Barely perceptible Severe

motion dysfunction
Absent Synkinesis,
contracture
,spasm
6 No movement , Total
loss of tone , Paralysis
No Synkinesis ,
contracture or
spasm
TOPOGNOSTIC TESTING
1. Schirmer test for lacrimation (GSPN)
Geniculate ganglion & petrosal nerve function
test
• Schirmer’s test +ve when
• Affected side shows less than half the amount of
lacrimation seen on the normal side
• Sum of the lengths of wetted filter paper for
both eyes less
than 25 mm
• Lesion at or proximal to the geniculate ganglion.

2. Stapedial reflex test (Stapedial branch)

Nerve to stapedius muscle test
• Impedence audiometry can record the presence
or
absence of stapedius muscle contraction to
sound
stimuli 70 to 100 db above hearing threshold
• An absence reflex or a reflex less than half the
amplitude is due to a lesion proximal to
stapedius
nerve

3. Taste testing (Chorda tympani nerve)

• Chorda tympani nerve test

• Solution of salt, sugar, citrate, quinine or
Electrical
stimulation
• Compares amount of current required for a
response each side
of tongue.

4. Salivary flow rates & pH (Chorda tympani)

Electrophysiologic test =
1. Nerve excitability test (NET)
The nerve is stimulated at steadily increasing
intensity till
facial twitch is just noticeable and compared with
the
normal side.
When the difference between 2 sides exceeds 3.5
milliamps, the test is positive for degeneration.

2. Electromyography(EMG)
Electromyography: EMG
Tests the motor activity of facial muscles by
direct
insertion of needle electrodes (usually in
orbicularis oculi & orbicularis oris) – record at
rest
and voluntary contraction of muscle.
Biphasic and Triphasic potentials - Normal resting
muscle
Fibrillation potentials – Denervated muscle
Polyphasic potentials- Regeneration of the nerve.
3. Maximal stimulation test (MST)
Maximum stimulation Test: MST
Similar to nerve excitability test, but instead of
measuring
the threshold of stimulation , the current level
which gives
maximum facial movement is determined and
compared
with the normal side.
Reduced or absent response indicates
degeneration and is
followed by incomplete recovery.

4. Electroneuronography (ENoG)
Facial nerve is stimulated at the
stylomastoid foramen and
compound muscle action
potentials are picked up by the
surface electrodes. Response of
action potentials are compared
with that on the normal side.
% of degenerating fibres is
calculated
>90% ---- indicates poor prognosis
This test is most useful between
14-21 days of the onset of
complete paralysis