NIGERIAN NAVY REFERENCE HOSPITAL OJO, LAGOS

PHYSIOTHERAPY DEPARTMENT

A PRESENTATION ON FACIAL NERVE/BELLS PALSY

BY

IKWUNEME, MICHAEL CHISOM

ON
5TH JULY, 2023
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FACIAL PALSY
INTRODUCTION 3

• Facial nerve palsy is a condition that affects the facial nerve, which controls
the muscles on one side of the face
• This causes weakness or paralysis of the facial muscles with presentations
like;
 Drooping of the mouth or eye
 Difficulty closing one eye
 Drooling
 Decreased or absent sense of taste.
 DEFINITION 4

• A facial palsy is weakness or paralysis of the muscles of the face

• Bell’s palsy (a type of facial nerve palsy) is an acute peripheral
facial palsy presented as sudden weakness or paralysis of
muscles on one side of the face due to malfunction of the 7th
cranial nerve (facial nerve).
 SCOPE
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 Relevant Anatomy
 Epidemiology
 Etiology
 Pathophysiology
 Clinical Presentation
 Differential Diagnosis
 Diagnosis
 Interventions
 Prognosis
 Outcome Measures
 RELEVANT ANATOMY
• FACIAL NERVE 6
 The facial nerve is the seventh cranial nerve which controls
the muscles of the face.
 It is responsible for facial expression, taste sensation in the
front two-thirds of the tongue, and the secretion of tears
and saliva
 It originates from the pons (originating as separate sensory
and motor roots),
 It passes through the internal acoustic meatus, very close to
the inner ear
 It then enter the facial canal where the two roots fuse to
form a single facial nerve
RELEVANT ANATOMY CONT’D 7

 It then gives off the intracranial branches of the greater

petrosal nerve, nerve to stapedius, and chorda tympani.
 The facial nerve then exits the facial canal (and the
cranium) via the stylomastoid foramen.
 The first extracranial branches given off are the posterior
auricular nerve, nerve to digastrics, and nerve to stylohyoid.
 The facial nerve then enters the parotid gland, dividing into
terminal branches of the Temporal, Zygomatic, Buccal,
Marginal mandibular, and Cervical branches.
RELEVANT ANATOMY CONT’D
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RELEVANT ANATOMY CONT’D 9
RELEVANT ANATOMY CONT’D
MUSCLES OF FACIAL EXPRESSION 10
• The muscles of facial expression are located within the subcutaneous tissue of
the face.
• They originate from bone or fascia and insert onto the skin.
• As they contract, the muscles pull on the skin to exert their effects.
• They are divided into the following 3 groups:
• Orbital Group: Orbicularis Oculi, Corrugator Supercilii, Occipitofrontalis
• Nasal Group: Nasalis, Procerus, Depressor Septi Nasi
• Oral Group : Orbicularis Oris, Buccinator, Platysma, depressor anguli oris,
depressor labi inferioris, mentalis, risorius, zygomaticus major, zygomaticus
minor, levator labii superioris, levator labii superioris alaeque nasi and levator
anguli oris
RELEVANT ANATOMY CONT’D
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MUSCLES OF FACIAL EXPRESSION
RELEVANT ANATOMY CONT’D
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EPIDEMIOLOGY 13
• Most population studies generally show an annual incidence of facial palsy
with 15–30 cases per 100,000 population
• Bell palsy is thought to account for approximately 60–75% of cases of acute
unilateral facial paralysis
• At present, no clear evidence exists to suggest facial nerve palsies are more
likely in any gender or race, and all ages could be affected.
• However, studies have shown that facial nerve palsies most commonly
affect individuals between the ages of 15 to 45 years
 TYPES 14
• Central facial nerve palsy:
 Occurs due to damage above the level of the facial
nucleus.
 The most common cause can be the condition of stroke.
 The symptoms of facial palsy will be limited to the lower
half of the face.
• Peripheral Facial Nerve Palsy:
 In Peripheral facial palsy, there will be complete paralysis
of one side of the face.
 Both the upper and lower half of the facial muscles will
become affected.
TYPES CONT’D 15

Peripheral facial palsy can be as a result of;

 Parotid gland pathology :
 tumor
 inflammation of gland itself.
 during the surgical procedure, any kind of pathology
occurs.
 Compression
 ETIOLOGY
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• Congenital
 A very small number of babies are born with congenital dysfunction of the facial
nerve.
• UMN causes,
 such as a stroke, subdural haematoma, or a brain tumour
 This will present with forehead sparing
• LMN causes
 Infective; such as acute otitis media, viral infection, Lyme disease
 Neoplasm (parotid malignancy)
 Trauma or iatrogenic
 ETIOLOGY CONT’D
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• Idiopathic
 Most commonly, the cause for facial nerve palsy remains unknown and was
tagged Bell’s palsy
 However, Current evidence suggests that there are common viral causes of Bells
palsy which includes;
 Herpes simplex virus infection (most common)
 Herpes zoster (possibly the second most common)
 Other viral causes include, COVID 19, coxsackievirus, cytomegalovirus,
adenovirus, and the Epstein-Barr, mumps, rubella, and influenza B viruses.
 Hence, the term "Bell palsy" is not always considered synonymous with
idiopathic facial nerve palsy
 PATHOPHYSIOLOGY
18
• The facial muscles are innervated peripherally (infranuclear innervation) by the
ipsilateral 7th cranial nerve and centrally (supranuclear innervation) by the
contralateral cerebral cortex.
• Central innervation tends to be bilateral for the upper face (eg, forehead
muscles) and unilateral for the lower face.
• As a result, both central and peripheral lesions tend to paralyze the lower face.
However, peripheral lesions (facial nerve palsy) tend to affect the upper face
more than central lesions (eg, stroke) do.
 PATHOPHYSIOLOGY
19
• The mechanism of Bells palsy is the swelling of the facial nerve due to an
immune or viral disorder.
• When the nerve is swollen, it is compressed by the narrow passageways in the
skull
 CLINICAL PRESENTATION
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• Appearance and Range of Movement
 Inability to close the eye
 Absence of horizontal lines on the forehead on the affected side
 Affected eye larger/more open than the unaffected one
 Lack of blink on the affected eye
 Altered position or absence of the naso-labial fold on the affected side
 Inability to move the lips (e.g. into a smile, pucker)
 At rest, the affected side of the face may "droop"
 Facial asymetry
 Ectropion - i.e. the lower eyelid may droop and turn outward
CLINICAL PRESENTATION CONT’D
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 CLINICAL PRESENTATION CONT’D
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• Functional Effects
 Difficulty eating and drinking as the lack of lip seal makes it difficult to keep
fluids and food in the oral cavity
 Reduced clarity of speech as the "labial consonants" (i.e. b, p, m, v, f) all
require lip seal
 People may be unable to taste with the front part of the tongue on the
affected side.
 The ear on the affected side may perceive sounds as abnormally loud (a
condition called hyperacusis) because the muscle that stretches the
eardrum is paralyzed. This muscle is located in the middle ear.
 Patients may report a numb or heavy feeling in the face.
 DIFFERENCIAL DIAGNOSIS
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 Historically, Bell palsy was thought to be idiopathic facial nerve (peripheral
7th cranial nerve) palsy. However, Bell’s palsy is now considered a clinical
syndrome with its own differential diagnosis
 Peripheral facial nerve palsy can be distinguished from a central facial nerve
lesion (eg. due to hemispheric stroke or tumor), which causes weakness
primarily of the lower face, sparing the forehead muscle and allowing
patients to wrinkle their forehead; also, patients with central lesions can
usually furrow their brow and close their eyes tightly.
 Usually, clinicians can also distinguish Bell’s palsy from other disorders that
cause peripheral facial nerve palsies based on their characteristic symptoms
and signs and causes;
DIAGNOSIS 24
• Laboratory investigations include an audiogram, nerve conduction studies,
Electroneurography (ENOG), computed tomography (CT) or magnetic
resonance imaging (MRI), electromyography (EMG)
• Blood tests such as a full blood count, urea and electrolytes, and a C-
reactive protein is necessary for all patients admitted due to an infectious
cause of facial palsy.
• Examinations like
 Salivary Test
 Taste test
 Measurement for facial asymmetry
 Observing the actions of muscles of facial expression
 INTERVENTIONS 25

• MEDICATION
 Bell's palsy can be treated with corticosteroids, given within 72 hours of
onset. This can be accompanied by antiviral medication.
• SURGICAL MANAGEMENT
 Tumours such as acoustic neuromas and facial schwannomas are
frequently resected surgically. Patients at high risk of a corneal ulcer may
be offered oculoplastic surgery to protect the eye.
 Facial reanimation surgeries which involve nerve graft or anastomosis
 Facial reanimation surgeries which involve muscle transposition
 INTERVENTIONS CONT’D
 PHYSIOTHERAPY MANAGEMENT 26
• GOALS
 Improve muscle strength
 Flexibility
 Range of motion
 Overall facial function
• INTERVENTIONS
 Facial exercises
 Electrical stimulation
 Biofeedback
 Facial massage
 Education and lifestyle modifications
 INTERVENTIONS CONT’D 27

• Facial exercises:
 This is one of the most common physiotherapy interventions for
facial nerve palsy.
 These exercises can help strengthen the affected muscles of the
face, improve muscle tone, and prevent muscle wasting.
 The physiotherapist may teach the patient a series of exercises
that target the specific muscles affected by the condition.
 INTERVENTIONS CONT’D 28

• Massage and soft tissue mobilization:

 Physiotherapists may use massage and other soft tissue
mobilization techniques to gently manipulate the soft tissues of
the face, including the muscles, fascia, and connective tissue.
 This can help increase blood flow to the area, improve lymphatic
drainage, and promote healing and recovery.
 INTERVENTIONS CONT’D 29

• Electrical stimulation:
 This technique involves the use of electrical currents to stimulate
the muscles and nerves.
 This can be particularly useful for patients with more severe cases
of facial nerve palsy, as it can help improve muscle strength and
tone, and speed up the recovery process.
 INTERVENTIONS CONT’D 30

• Biofeedback:
 This technique involves monitoring muscle activity using sensors
and providing visual or auditory feedback to the patient.
 This can help improve muscle control and coordination, and
promote better movement patterns.
 INTERVENTIONS CONT’D 31

• Education and lifestyle changes:

 Physiotherapists can also provide education and advice on
lifestyle changes that can help improve facial nerve palsy
symptoms,
 such as avoiding alcohol and caffeine, maintaining a healthy diet,
and avoiding stress.
PROGNOSIS
• The likelihood of complete recovery after total paralysis is 90% if nerve32
branches in the face retain normal excitability to supramaximal electrical
stimulation and is only about 20% if electrical excitability is absent.
• With immediate management, complete recovery can be achieved within
three to six months
• The factors that suggest a poor prognosis from a facial palsy include:
 Complete palsy
 No signs of recovery within 3 weeks
 Age >60yrs
 Associated pain
 Associated hypertension, diabetes mellitus, or pregnancy
 Complete No signs of recovery within three weeks
OUTCOME MEASURES
• Sunnybrook facial grading system 33
 Generally preferred by physiotherapists because of its sensitivity, and the section on
synkinesis
 The regions of the face are evaluated separately, with the use of five standard expressions:
 Eyebrow raise, Eye closure, Open mouth smile, lip pucker and Snarl / show teeth
• House-Brackmann facial nerve grading scale
• Synkinesis assessment questionnaire
• Linear measurement index
• Facial disability index
• Lip-length (LL) and snout (S) indices
• Five-point scale
OUTCOME MEASURES CONT’D
34
•House-Brackmann classification of facial palsy
A B
Grade Description
1 i Normal symmetrical function throughout
2 ii Slight weakness on close inspection + slight asymmetry of smile
3 iii Obvious non-disfiguring weakness, complete eye closure
4 iv Obvious disfiguring weakness, cannot lift the brow, incomplete
eye closure, severe synkinesis
5 v Barely perceptible motion, incomplete eye closure, slight
movement of corner of mouth, absent synkinesis
6 vi No movement, atonic
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CONCLUSION

It is important to seek medical attention as soon as possible.

Early treatment can improve the chances of a full recovery.
REFRENCES 36
• Mayo Clinic. Bell’s palsy - Symptoms and causes [Internet]. Mayo Clinic. 2018.
Available from:
https://www.mayoclinic.org/diseases-conditions/bells-palsy/symptoms-causes/syc-20370
028
• Facial Palsy - Causes - Differential Diagnosis - Management - TeachMeSurgery
[Internet]. TeachMeSurgery. 2017. Available from:
https://teachmesurgery.com/ent/presentations/facial-palsy/
• Chauhan S. The Facial Nerve: Anatomical course, Functions, and Clinical importance
[Internet]. Samarpan Physiotherapy Clinic Ahmedabad. 2022 [cited 2023 Jun 21].
Available from: https://mobilephysiotherapyclinic.net/facial-nerve-anatomy/
• Walker NR, Mistry RK, Mazzoni T. Facial Nerve Palsy [Internet]. PubMed. Treasure
Island (FL): StatPearls Publishing; 2020. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK549815/
REFRENCES CONT’D 37
 Rubin M. Facial Nerve Palsy - Neurologic Disorders [Internet]. MSD Manual
Professional Edition. MSD MANUAL; 2022 [cited 2023 Jul 4]. Available from:
https://www.msdmanuals.com/professional/neurologic-disorders/neuro-
ophthalmologic-and-cranial-nerve-disorders/facial-nerve-
palsy#:~:text=Pathophysiology%20of%20Facial%20Nerve
%20Palsy&text=Central%20innervation%20tends%20to%20be