Transcript AHeatley Bell`s Palsy 13APR2016x

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.,
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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/