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BELL PALSY IDIOPATHIC FACIAL MONONEUROPATHY Ashley Heatley NURS870 WHAT IS BELL PALSY? ABRUPT PARALYSIS OF THE 7TH CRANIAL NERVE ANATOMY REVIEW 7TH CRANIAL NERVE EXITS THE RESULT OF DAMAGE OR TRAUMA TO THE FACIAL NERVE THAT CAUSES SWELLING, INFLAMMATION OR COMPRESSION APPROXIMATELY 40,000 AMERICANS PER YEAR MOST COMMON AGES 15-60 EQUAL IN MALES:FEMALES 80% OF ALL FACIAL MONONEUROPATHIES ARE BELL PALSY THIS IS THE MOST COMMON CAUSE OF FACIAL PARALYSIS 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 http://www.peerie.com/Research/2609/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 FACIAL DROOP WEAKNESS DROOLING PARALYSIS EYELID DROOPING JAW DISCOMFORT DRYNESS OF THE EYE EXCESSIVE TEARING OF DIFFICULTY EATING OR THE EYE HEADACHE DIZZINESS IMPAIRMENT OF TASTE DRINKING IMPAIRED SPEECH TINNITUS HYPERSENSITIVITY TO SOUND POSTAURICULAR PAIN OBJECTIVE DATA COLLECTION PURPOSE IS TO SEARCH FOR AN UNDERLYING CAUSE REVIEW OF SYSTEMS FACIAL TRAUMA SKULL FRACTURE? FACIAL INJURY? PAST MEDICAL HISTORY DIABETES HYPERTENSION HYPOTHYROIDISM PREGNANCY EAR INFECTION LYMES DISEASE HERPES ZOSTER MALIGNANCY TICK BITE SARCOIDOSIS INFLUENZA (OR RECENT SJOGREN SYNDROME INTRANASAL VACCINATION) HEAD OR NECK 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 https://12cranialnerves.files.wordpress.com/2012/04/bells_palsy_pictures-564.gif 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 10.117710194599813505967 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 (527-580). St. Louis, MO. Cash, J.C. (2014). Bell’s Palsy. In Cash, J.C. & Glass, C.A. (Eds.), Family Practice Guidelines (585-587). New York, NY. National Institutes of Neurological Disorders and Stroke. (2016). Bell’s Palsy Fact Sheet. Retrieved from http://www.ninds.nih.gov/disorders/bells/ 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 (1269-1272). Philadelphia, PA. Taylor, D.C.(2015). Bell Palsy. Retrieved from http:// emedicine.medscape.com/article/1146903-overview Questions? http://www.icr.org/article/science-man-god-charles-bell/