
Bell's palsy or facial nerve palsy.
Bell's palsy is a weakness of the facial muscles. It develops suddenly, usually on one side of the face. The cause is not clear but most cases are probably due to a virus infection. Most people make a full recovery within 2-3 months. A course of steroid tablets started within 72 hours of the onset improves the chance of full recovery even further. You should protect your eye if you cannot close your eyelids fully.
What is Bell's palsy?
What is the facial nerve?
Neuroanatomy
The VII th cranial (facial) nerve is largely motor in function (some sensory fibres from external acoustic meatus, fibres controlling salivation and taste fibres from the anterior tongue in the chorda tympani branch). It also supplies the stapedius (so a complete nerve lesion will alter auditory acuity on the affected side). From the facial nerve nucleus in the brain stem, fibres loop around the VI nucleus before leaving the pons medial to VIII and passing through the internal acoustic meatus. It passes through the petrous temporal in the facial canal, widens to form the geniculate ganglion (taste and salivation) on the medial side of the middle ear whence it turns sharply (and the chorda tympani leaves), to emerge through the stylomastoid foramen to supply all the muscles of facial expression including platysma.


Anyone can get Bell's palsy, and it affects both men and women equally. It most commonly occurs between the ages of 10 and 40. Bell's palsy is the most common cause of a sudden facial weakness. About 1 in 70 people has a Bell's palsy at some stage in their life.

It is thought that inflammation develops around the facial nerve as it passes through the skull from the brain. The inflammation may compress (squash) the nerve as it passes through the skull. The nerve then partly, or fully, stops working until the inflammation goes. If the nerve stops working, the muscles that the nerve supplies also stop working.
Weakness of the face which is usually one-sided. The weakness normally develops quickly, over a few hours or so. You may first notice the weakness after getting up in the morning, and so it may appear quite dramatic. It may gradually become worse over several days. The effects of the weakness vary, depending on whether the nerve is partially or fully affected. These include the following:
Your face may droop to one side. When you smile, only half of your face may move.
Chewing food on the affected side may be a problem. Food may get trapped between your gum and cheek. Drinks and saliva may escape from the side of your mouth.
. You may not be able to close an eye. This may cause a watery or dry eye.
. You may not be able to wrinkle your forehead, whistle or blow out your cheek.
. You may have some difficulty with speech, as the muscles in the side of the face help in forming some words. For example, words beginning with a P.

. Loud sounds may be uncomfortable and normal noises may sound louder than usual. This is because a tiny muscle in the ear may stop working.
. You may lose the sense of taste on the side of the tongue that is affected.
No. Bells palsy is a local problem confined to the facial nerve and facial muscles. If you have other symptoms, such as weakness or numbness in other parts of your body, there will be another cause and you should tell your doctor.
Other conditions that may be confused with Bell's palsy
Bell's palsy is a common cause of a facial palsy. Less commonly, facial palsy is caused by other things that can damage or affect the facial nerve. For example: a head injury, sarcoidosis, Lyme disease, growths in the ear, tumours in the parotid gland and tumours in the brain. Also, some people who have a stroke develop facial weakness. With these conditions you are likely to have other symptoms too. This helps doctors to tell the difference between a Bell's palsy and other causes of a facial palsy.
With a stroke, the forehead muscles are not affected. Also, you are likely to have other nerves that are affected in addition to the facial nerve.
Without treatment, full recovery is still likely and occurs in about 15 in 20 cases. With treatment, the chance of full recovery is improved (see below). In most people the function of the nerve gradually returns to normal. Symptoms usually start to improve after about 2-3 weeks, and have usually gone within two months. In some cases, it can take up to twelve months to recover fully.In some cases, symptoms do not completely go. Some weakness may remain for good. However, it is often a slight weakness of part of the face and hardly noticeable. It is uncommon to have no improvement at all; however, some people are left with some degree of permanent facial weakness.
Do I need any tests?
When a doctor sees a patient with a sudden facial muscle weakness, he or she will aim to rule out other causes of the problem before diagnosing Bell's palsy. Most other causes can be ruled out by the absence of other symptoms, and a by doctor's examination. No tests may be needed.

As mentioned, there is a good chance of full recovery without any treatment. However, drug treatment is usually advised to improve the chance of full recovery even more. Also, you need to protect your eye if your eyelids cannot close (see below).
Drug treatment is still controversial and intradepartmental variation exists.
· Steroids - Most now give 7-10 days of prednisolone (1mg/kg/day - adult 60-80 mg/day) as early as possible (ideally within 72 hours), either alone or with antivirals because this study showed steroids result in more complete recovery rates at 3 and 9 months.
· Antivirals - There is less evidence for the use of antivirals in the absence of any viral vesicles.

· Surgery - Surgical transmastoid decompression of the facial nerve in severe cases is being investigated but cannot currently be recommended. Where nerve fails to regenerate, cosmetic surgery to elevate mouth or anastomosis of hypoglossal nerve to the facial nerve may help.
Prognosis
71% of untreated patients with idiopathic non progressive Bell's palsy recover completely (84% have near-normal function) usually within a few weeks.

· Complete palsy or severe degeneration (electrophysiology)
· No signs of recovery by three weeks
· Age >60
· Severe pain
· Ramsay Hunt syndrome (herpes zoster virus)
· Associated with either hypertension, diabetes, or pregnancy
If you cannot close your eyelids fully, the front of your eye is at risk of becoming damaged. Also, your tear glands may not work properly for a while and your eye may become dry. Dryness could cause damage, so treatment is needed to keep the eye moist.

. An eye pad or goggles to protect the eye.
. Eye drops to lubricate the eye during the day.
. Eye ointment to lubricate the eye overnight.
For the small number of cases where the facial weakness does not recover fully, and remains unsightly, some techniques may be considered. For example:
A treatment called, 'facial retraining' with facial exercises may help.
Various surgical techniques can help with the cosmetic appearance.

In most cases, a Bell's palsy is a 'one-off'. About 1 in 10 people who have a Bell's palsy can have a further episode sometime in the future, often several years afterwards.
Presentation
. Weakness of the muscles of facial expression and eye closure.
· In partial paralysis, lower face is generally more affected.
· In severe cases, there is often demonstrable loss of taste over front of tongue and intolerance to high pitched or loud noises. May cause mild dysarthria and difficulty with eating.

· In an UMN lesion, the upper facial muscles are partially spared because of alternative pathways in the brainstem i.e. the patient can wrinkle their forehead (unless bilateral lesion) and the sagging of the face seen with lower motor neurone palsies is not as prominent. There appear to be different pathways for voluntary and emotional movement.
Investigations
· Serology - lyme, herpes and zoster (paired samples 4-6 weeks apart). It may not influence management, but may reveal aetiology.
· Check blood pressure in children with Bell's palsy (2 case reports of aortic coarctation presenting with facial nerve palsy and hypertension).
· The following tests are rarely done but combined with a good understanding of the neuroanatomy can determine the level of the palsy:
· Schirmer tear test (reveals reduced flow of tears on the side of a palsy affecting the greater palatine nerve).
· Stapedial reflex (an audiological test absent if stapedius muscle is affected).
· Electrodiagnostic studies (generally a research tool) reveal no changes in involved facial muscles for the first three days, but a steady decline of electrical activity often occurs over the next week, and will identify the 15% with axonal degeneration.
Bell's palsy management
Those with axonal degeneration may not show any re-innervation for three months, and recovery may be partial or not at all.Following this synkinesis is often seen e.g. blinking causes angle of mouth to contract. Also aberrant parasympathetic re-innervation may cause symptoms such as gustatory lacrimation ('crocodile tears'). Symptoms can be helped by subcutaneous or intramuscular injections of botulinum toxin.
A specific cause of Bell's palsy is unknown, however, it has been suggested that the disorder may be inherited. It also may be associated with:
. diabetes
. high blood pressure
. trauma
. toxins
. Lyme disease
. Guillain-BarrÉ syndrome
. sarcoidosis
. myasthenia gravis
. infection
. loss of feeling in the face
. headache
. tearing
. drooling
. loss of the sense of taste on the front two-thirds of the tongue
. hypersensitivity to sound in the affected ear
. inability to close the eye on the affected side of the face
. affects the muscles that control facial expressions such as smiling, squinting, blinking, or closing the eyelid

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HERBAL REMEDY BEST FOR YOU The most powerful feature of Traditional Chinese Medicine is that it allows you to easily combine multiple ingredients to form a recipe to suit the specific need of individual.

1 - Radix Angelicae Pubescentis
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