L iving with half a smile

Charise Leah A. Arcenas, MD

Objectives

 To discuss the approach to the diagnosis

and management of facial nerve
paralysis.
 M.R.T, 49/F
CC: Numbness on the right side of the face
 9 hours prior to admission 9 hours prior to admission
(5 am)

 Headache, frontal area, 5/10,

Sudden onset of
throbbing, lasting for 30
numbing sensation on minutes, non radiating,
the right side of face intermittent, sudden onset,
(described as “ slightly relieved by rest,
nangangapal) thought that the headache was
due to frequent sleeping late at
night
 Patient decided to sleep
 9 hours prior to admission

 No other associated symptoms

such as: chest pain, loss of
consciousness, drooling of saliva,
body weakness, slurring of
speech, dizziness, nausea,
vomiting, ear pain or discharge,
tinnitus, blurring of vision,
difficulty of breathing, fever,
cough and colds

 No medications taken
 1 hour prior to admission 1 hour prior to admission
(1 pm)

 Upon waking up, patient still

had numb sensation on the
 Still with Headache,
right side of face (described as
“nangangapal)
 Now associated with pulsating
sensation of the right side of
the cheek
frontal area, 3/10,
throbbing, non – radiating,
intermittent lasting for 30
minutes, thought that the
headache was due to
frequent sleeping late at
night
 1 hour prior to admission 1 hour prior to admission

 No other associated
While she was brushing
her teeth, she noticed that
the water was drooling on
the right side of her mouth
and inability to close her
right eye fully
symptoms such as: chest
pain, loss of consciousness,
body weakness , slurring of
speech, dizziness, nausea,
vomiting, ear pain or
discharge, tinnitus, blurring
of vision, difficulty of
breathing, fever, cough and
colds

 Decided to consult at the E.R

 Past Medical History:
 Diagnosed with hypertension last 2018 prescribed with
Losartan 50 mg/tab, ½ tablet once a day and Atorvastatin 40
mg/tab, once a day
 Usual BP of 120/80 mmHg
 Highest BP: 140/90 mmHg
 Totally stopped taking her medications and was lost to follow
up, no regular BP monitoring done (took her medications twice
or thrice only)
 Had childhood illness such as measles and chickenpox
 Past Medical History:
 No known history Diabetes mellitus , Bronchial asthma,
lung, heart, kidney, liver, thyroid disease
 No previous history of blood transfusion or accidents
 No previous history of cerebrovascular diseases
G
E
N
O
G
R
A
M
 OBSTETRICS and GYNECOLOGIC
HISTORY
 Menarche: 10 years old
 Interval: 27 – 31 days
 Duration: 5 – 7 days
 Amount: 3 pads moderately soaked
 Symptoms: none
 OBSTETRICS and GYNECOLOGIC
HISTORY
 LMP: February 20, 2020
 PMP: 3rd week of January
 Gravida 2 Para 1: (1011)
 Gravida 1: born on 1998, female, via Cesarean section due to
CPD
 No history of contraceptive use, STD
 Coitarche: 21 years old
 # sexual partners: 1
 PERSONAL AND SOCIAL HISTORY
 Patient is a college graduate and works as a human resource
director
 Married for 28 years
 She is a non smoker, non alcoholic beverage drinker
 Sleeps for at least 3 to 5 hours every night, poor quality of sleep
 Currently residing at a 2 storey house, well lit, well ventilated with
her husband and daughter
 PERSONAL AND SOCIAL HISTORY

 Water source is from Maynilad and garbage is collected 2x a

week, segregated

 Lives a sedentary lifestyle and does not have any form of

exercise

 Fond of eating chips and salty foods

 REVIEW OF SYSTEMS:
 Constitutional: (-) weight loss (-) anorexia
 HEENT: (-) use of eyeglasses, (-) anosmia, (-) epistaxis,
(-) nasal obstruction, (-) hoarseness of voice, (-) gum bleeding, (-) dentures
 Skin: (-) pruritus, (-) erythema, (-) diaphoresis, (-) pallor, (-) jaundice
 Respiratory: (-) chest pain on deep breathing
 Cardiovascular: (-) sub-sternal pain, (-) easy fatigability
 GIT: (-) diarrhea, (-) constipation
 REVIEW OF SYSTEMS:
 GUT: (-) urinary frequency, (-) urgency, (-) polyuria, (-)
incontinence
 Nervous: (-) vertigo, (-) confusion
 Extremities: (-) bipedal edema, (-) deformities, (-) joint pain
 Hematologic: (-) easy bruisability
 Endocrine: (-) intolerance to heat/cold, (-) excessive weight
change, (-) polyuria, (-) nocturia (-) polydipsia,(-) polyphagia (-)
disturbance in taste
 PHYSICAL EXAMINATION

 General Survey: Patient is conscious, coherent, not in cardiorespiratory

distress,
BP: 180/100 mmHg – 180/100 mmHg - 160/100 mmHg
HR: 78bpm RR: 20pm Temperature: 36.5°C O2: 98%
Weight: 83kg Ht: 163 cm BMI: 31.2 (Obese II)
 PHYSICAL EXAMINATION

HEENT: pink palpebral conjunctiva, anicteric sclerae, with ptosis of

the right eye, pink turbinates, no nasoaural discharge, shallow
nasolabial fold, right, lips are pink, moist with drooping of the right
side of the mouth and drooling of saliva. No tonsillopharyngeal
congestion, no oral ulcers or cold sores noted, symmetrical auricles, no
lesions, mass and tenderness on the external ear and mastoid area,
intact tympanic membrane, no discharge, no swelling or redness of the
walls of the ear canal
 PHYSICAL EXAMINATION

 NECK: Supple neck, no neck vein distention, no palpable lymph nodes, no

mass noted

 LUNGS: Symmetrical chest expansion, no retractions, no lagging, clear breath

sounds

 HEART: Adynamic precordium, normal rate, regular rhythm, no murmur

 PHYSICAL EXAMINATION

 ABDOMEN: Abdomen is flabby, soft, non tender. Bowel sounds are

normoactive, no bruit heard no mass, non-palpable liver edge, and non-palpable
spleen.

 EXTREMITIES: no gross deformities, full and equal pulses, CRT < 2

seconds, no edema
 PHYSICAL EXAMINATION

 Neurologic examination: General

 GCS 15
 Conscious, coherent, oriented to time, place and person
Intact recent, remote and immediate memory
Dressed appropriately, looks her age
No mannerisms noted
Slurred speech
 PHYSICAL EXAMINATION

 Neurologic examination: Cranial Nerves

I. Able to smell
II. Pupils are 2 - 3 mm, equally reactive to light, visual
fields are full by confrontation, NVA: J2
III.IV, VI. Intact extraocular muscles
 PHYSICAL EXAMINATION

 Neurologic examination: Cranial Nerves

V. Impaired corneal reflex, able to clench teeth, intact

sensation

VII. Unable to fully close right eye, unable to pout lips and
puff cheeks, unable to lift right eyebrow
 PHYSICAL EXAMINATION
 Neurologic examination: Cranial Nerves

VII. Intact gross hearing, Rinne: positive (air and bone conduction retained
Weber: Heard equally on both sides

IX. X. Intact gag reflex, no hoarseness of the voice

XI. Can shrug shoulder, able to move head from side to side

XII. Tongue is midline upon protrusion; no fasciculation Uvula is at the midline.

 Physical Examination
Signs of meningeal irritation: no nuchal rigidity, No Kernig's, No Brudzinski, No Babinski
Motor function Sensory function Deep Tendon Reflex
5/5 5/5 100% 100% +2 +2

5/5 5/5 100% 100% +2 +2

Cerebellum: no nystagmus, no tremors, no dysmetria, no

dysdiadochokinesia, no abnormal gait noted, normal heel to shin test and
finger to nose test

Pronator drift, Romberg test - negative

Salient features:
49/F
 Hypertensive, totally
stopped taking prescribed
medications
 Non smoker, non
alcoholic drinker
 Poor quality of sleep
X chest pain
X loss of consciousness
X body weakness
 Sudden onset of numbness of X dizziness
the right side of the face X nausea
 Headache X vomiting
 Throbbing sensation on the X ear pain, discharge, tinnitus,
X blurring of vision
cheek
X fever
 Drooling on the right side of the X cough and colds
mouth
 Unable to fully close the right
eye
  Drooping of the right side
of the mouth and drooling
of saliva
 Impaired corneal reflex

Vital signs:

BP: 160-180/100 mmHg

 Shallow right nasolabial HR: 78bpm
RR: 20pm
fold Temperature: 36.5°C
 unable to fully close right O2: 98%
eye Weight: 83kg Ht: 163 cm
 unable to pout lips and BMI: 31.2 (Obese II)
puff cheeks
 smoothening out of the
right forehead
Differential Diagnosis:
 Facial
Palsy

Central Peripheral

STROKE BELL’S PALSY

 Stroke Bell’s Palsy

Course Seconds to minutes Hours to days

Hypertension Yes Possible

Upper part of the face Not affected Affected

Lower part of the face Affected Affected

Upper/ Lower Extremity Often present Not present

weakness

Altered level of consciousness Possible None

Cerebellar dysfunction Present Absent

Imaging result With abnormal findings None

 Admitting Diagnosis

 Hypertensive Urgency
 Facial palsy, Right
 T/C Bell’s Palsy
 Rule out cerebrovascular accident
 Obesity
 Management:

 Diagnostics done at the ER:

 CBC with PC
 Sodium
 Potassium
 BUN
Creatinine
SGPT
CBG
12 Lead ECG
Cranial DW MRI
* Last meal : 1 hour
before CBG, 2 pcs biscuit
and ½ cup milk
 Initial DWMRI

 Unremarkable
 Management:

 Therapeutics:
Losartan 50 mg/tab, 1 tablet once a day per orem
Atorvastatin 40 mg/tab, 1 tablet once a day per orem
Clonidine 75 mcg/tab,1 tablet as needed per orem
 Management:

 Diet:
 Low salt, low fat, soft diet with strict aspiration precaution

 Intravenous Fluid
IVF: Plain Normal Saline Solution x 60 cc/hour
Course in the ward
 Day of admission
(March 8, 2020)
Subjective:
 Numbness on the right side
of the face
 Still with occasional
headache, intermittent,
3/10, frontal area
throbbing, lasting for 30
minutes to 1 hour, relieved
by rest
Day of admission
(March 8, 2020)
 Drooling on the right side of her
mouth
 Inability to close her right eye
fully
 No nausea, vomiting, chest pain,
body weakness, dizziness,
blurring of vision, difficulty of
breathing, loss of consciousness
 Day of admission
(March 8, 2020)
Objective:
 Ptosis of the right eye
 Vital signs:
 Impaired corneal reflex
BP: 140- 180/90- 100
 Shallow right nasolabial fold
CR: 95- 98 bpm
 Drooping of the right side of
RR: 20 cpm
the mouth and drooling of
T: 36.5 – 37.1
saliva
O2: 96-99
 Unable to pout lips and puff
cheeks
 Unable to frown
 GCS 15, oriented to time,
 Other neurologic
place and person,
examination were normal
conscious, coherent
 Slurred speech
 Day of admission
(March 8, 2020)

Plan:

Diagnostics
Plan:
 For Lipid Profile
 Fasting Blood sugar
 Hemoglobin a1c IVF: PNSS x 60 cc/hr
Diet: Low salt, low fat soft
Therapeutics:
 Losartan 50 mg/tab, 1 tablet once a
diet with strict precaution
day per orem
 Atorvastatin 40 mg/tab, 1 tablet
once a day per orem
 Clonidine 75 mcg/tab, 1 tablet as
needed per orem
 Day 2
(March 9, 2020)
Subjective:
 Numbness on the right side
of the face – lesser
pangangapal
 Minimal drooling of water when
brushing
 Burning sensation on the right
eye on prolonged reading
 Throbbing sensation on the
cheek
 Unable to fully close the right
eye
 No more headache
 No nausea, vomiting, chest pain,
dizziness, blurring of vision,
difficulty of breathing, loss of
consciousness, decreased taste
 Day 2
(March 9, 2020)
Objective:
 Ptosis of the right eye
 Vital signs:  Impaired corneal reflex
BP: 130- 140/80-90  Shallow right nasolabial fold
CR: 73-86 bpm  Drooping of the right side of
RR: 19-20 cpm the mouth and drooling of
T: 36.5 – 36.7 saliva
O2: 97-99  Unable to pout lips and puff
cheeks
 Unable to frown
 GCS 15, oriented to time,  Other neurologic
place and person, examination were normal
conscious, coherent
 Slurred speech
 Day 2
(March 9, 2020)  Prednisone 20 mg/tab, 1
tablet 2x a day after meals
Plan:  Omeprazole 20 mg/tab, 1
tablet twice a day 30
Therapeutics: minutes before meals

 Losartan 50 mg/tab, 1 Plan:

tablet once a day per
orem  IVF: PNSS x 60 cc/hr
 Atorvastatin 40 mg/tab,  Diet: Low salt, low fat soft
1 tablet once a day per diet with strict precaution
orem  Refer to Ophthalmology
 Day 2
(March 9, 2020)
 Family C.E.A was also
 Seen by Ophthalmology
done.
department.
 Anxiety > Reality
She was started on:

 Carbomer eye gel once a

day at night to right eye

 Sodium hyaluronate eye

drops, 1 drop to right eye 4x
a day

 Lid taping at night

ECM: “Stroke”

“Kala ko
mababalda na
siya eh”
 Anxiety > Reality

 High anxiety levels of the patient and husband

 Counselling was done to decrease the anxiety by
explaining the manifestations and laboratory results of the
patient
 Day 3
(March 10, 2020)
Subjective:
 Numbness on the right side
of the face – lesser
pangangapal
 Minimal drooling of water when
brushing
 Lesser burning sensation on the
right eye on prolonged reading
 Unable to fully close the right
eye
 No more throbbing sensation on
the cheek
 No more headache
 No nausea, vomiting, chest pain,
dizziness, blurring of vision,
difficulty of breathing, loss of
consciousness, decreased taste
 Day 3
(March 10, 2020)
 Ptosis of the right eye
 Impaired corneal reflex
Objective:  Shallow right nasolabial fold
 Drooping of the right side of
 Vital signs: the mouth and drooling of
BP: 120-140/80-90 saliva
CR: 84-97 bpm  Unable to pout lips and puff
RR: 19-20 cpm cheeks
T: 36.5 – 36.6  Unable to frown
O2: 97-99  Other neurologic
examination were normal
 GCS 15, oriented to time,
place and person,
conscious, coherent
 Improved speech
 Day 3
(March 10, 2020)
 Prednisone 20 mg/tab, 1
tablet 2x a day after meals
 Omeprazole 20 mg/tab, 1
Plan:
tablet twice a day 30
minutes before meals
Therapeutics:
 Carbomer eye gel once a
 Losartan 50 mg/tab, 1 day at night to right eye
tablet once a day per
 Sodium hyaluronate eye
orem
 Atorvastatin 40 mg/tab, drops, 1 drop to right eye 4x
a day
1 tablet once a day per
orem
 Patient was discharged on the 3rd hospital day

Home medications:
 Losartan 50 mg/tab, 1 tablet once a day
 Atorvastatin 40 mg/tab, 1 tablet once a day
 Prednisone 20 mg/tab, 1 tablet 2x a day after meals for 3 more days (40mg/day),
then 20 mg/ tab in the morning then 10 mg/ tab in the evening for 3 days (30
mg/day), then 10 mg/tablet 2x a day after meals for 3 days until follow up (20
mg/day)
 Omeprazole 20 mg/tab, 1 tablet twice a day 30 minutes before meals
 Carbomer eye gel once a day at night to right eye
 Sodium hyaluronate eye drops, 1 drop to right eye 4x a day
Discussion
 Bell’s Palsy/ Idiopathic Facial Palsy
 Named after Sir Charles Bell
 Most common form of facial paralysis
 A peripheral palsy of the facial nerve that results in muscle
weakness on one side of the face
 Incidence: 15 – 30 per 100,000 annually, no sex
predilection
 Can occur at any age but with peak incidence noted in the
40s
 Bell’s Palsy/ Idiopathic Facial Palsy

 Eitology:
 Idiopathic
 Possibly due to the inflammation of the facial nerve which leads
to possible decompression or demyelination which maybe caused
by:
 Viral ( Most commonly associated with HSV 1 and
herpes zoster)
 Infections
 Trauma
 Iatrogenic
 Risk Factors
 Family history
 Age - √ (Patient is 49 years old)
 Diabetes Mellitus
 Pregnancy
 Previous Bell’s Palsy (7%)
 Bell’s
Phenomenon
 Diagnostics:
 Bell’s palsy is a diagnosis of exclusion
 Often made clinically in patients with
a) typical presentation
b) no risk factors or preexisting symptoms for other causes of
facial paralysis
c) absence of cutaneous lesions
d) normal neurologic examination with the exception of facial
nerve
 Treatment options
 Oral Steroids
 Antivirals monotherapy
 Prednisone 40 - 60 mg/tab
1 tablet once a day (or divided  Aciclovir - 400mg/tab, 4x a day
doses) for 5 days then for 7 days
taper dose OR
or  Valacyclovir – 1g 3x a day for 7
 Prednisolone 25 mg/tab days
twice a day for 10 days

 Must be initiated within 72 hours of

symptom onset
 Combined steroids + Antivirals
 Treatment
 Eye Care
 Lubricating eyedrops
 Lid taping
 Surgical
 Physical therapy
 No recommendation
E.B.M on Therapy
 Prognosis
 Fair prognosis
 Improvement occurs within 3 weeks in 85%
 Those who do not show signs of improvement within 3
weeks may have severe degeneration of the facial nerve or
may have a different diagnosis
 71% will recover full facial muscle function, 29% are left
with mild to severe residual muscle weakness
 Updates about the patient

 “Doc, my Bell’s palsy 90% back to normal na yung right face ko , wala na yung
pangangapal. Maayos na din po ako nakakapagsalita”
 “Doc, araw araw na din po ako umiinom ng maintenance medicines ko. Pati si husband
regular na din umiinom ng kanya tapos doc yung BP ko po regular na ako nag
momonitoring madalas po nasa 108 – 121/ 74-85”
- April 8, 2020

 “98% recovered na ako from Bell’s palsy. Yung right eye ko mas nag improve na, mas
mabilis na yung pag blink saka konti na lang yung opening kapag sinasara ko yung
right eye ko, mas nakakakain na din ako ng maayos, no need na for straw”
- April 22, 2020
 Patient Education and Wellness plan
 For Pap Smear
 For Mammography
 Follow up Pneumococcal, dTap, flu vaccine
 Strict compliance to medications
 Daily BP monitoring and record
 Low salt, low fat, soft diet and drinking via straw is
helpful
 Patient Education and Wellness plan
 Weight loss
 30 minutes of aerobic exercise five times a week.
Ideal activities include brisk walking, bicycling,
swimming, or even dancing
 Follow up one week after then 3 weeks then 3 months
and 9 months or anytime if with new onset of
neurologic/ophthalmologic symptom
 Final Diagnosis

 Hypertensive urgency, controlled

 Bell’s Palsy, Right, House Brackmann Score 5
 Dyslipidemia
 Obesity
“
The human face after all is
nothing more nor less than a mask
”
- Agatha Christie
As your family physician, we will try our
best so you won’t have to live with half a
smile 
Department of Community and Family Medicine, FEU – NRMF
 Sources:
 American Association of Family Physician
 Marson, A. G., & Salinas, R. (2000). Bell's palsy. The Western journal of medicine, 173(4), 266–268.
https://doi.org/10.1136/ewjm.173.4.266
 Murthy, J. M., & Saxena, A. B. (2011). Bell's palsy: Treatment guidelines. Annals of Indian Academy of
Neurology, 14(Suppl 1), S70–S72. https://doi.org/10.4103/0972-2327.83092
 House, J.W., Brackmann, D.E. Facial nerve grading system. Otolaryngol. Head Neck Surg, [93] 146–147.
1985
 Sullivan FM, Swan IR, Donnan PT, Morrison JM, Smith BH, McKinstry B, Davenport RJ, Vale LD,
Clarkson JE, Hernández R, Stewart K, Hammersley V, Hayavi S, McAteer A, Gray D, Daly F, A
randomised controlled trial of the use of aciclovir and/or prednisolone for the early treatment of Bell's
palsy: the BELLS study., Health Technol Assess, 2009, 13, 47, iii-iv, ix-xi 1-130, doi: 10.3310/hta13470
 Harrison’s Principle of Internal Medicine, 19th edition
 Clinical Practice Guidelines: Bell’s Palsy, Basura, et. Al, American Academy of Otolaryngology, Head and
Neck Surgery