Thursday, November 12, 2009

Facial Nerve Palsy or Bell's palsy

Facial Nerve Palsy

Jean Chrétien He was the twentieth Prime Minister of Canada, serving for over ten years, from November 4, 1993 to December 12, 2003;.suffered from facial palsy.

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?

Bell's palsy is a weakness (paralysis) that affects the muscles of the face. It is due to a problem with the facial nerve. The weakness usually affects one side of the face. Rarely, both sides are affected. Many people who have a Bell's palsy at first think that they have had a stroke. This is not so. Bell's palsy is very different to a stroke and full recovery occurs in most cases. Bell's palsy is named after the doctor who first described it. Originally described by Sir Charles Bell in 1821. Incidence 20/100,000 between 10-40 years, but 59/100,000 over 65 years.Recent work suggests that a large number of these cases may be due to herpetic viral infection - particularly Herpes Simplex type 1, or Varicella (herpes) Zoster which clearly may have implications for

What is the facial nerve?


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.

You have a facial nerve (also called the seventh cranial nerve) on each side of your face. Each facial nerve comes out from your brain, through a small tunnel in your skull just under your ear.The nerve splits into many branches that supply the small muscles of the face that you use to smile, frown, etc. It also supplies the muscles that you use to close your eyelids.Branches of the facial nerve also take taste sensations from your tongue to your brain.

Who gets Bell's palsy?
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.

What causes Bell's palsy?
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.

The cause of the inflammation is not known; but, in most cases, it is probably due to a viral infection. There is some evidence that the cold sore virus (herpes simplex virus) or the chickenpox virus (varicella zoster virus) cause most cases of Bell's palsy. Most people have chickenpox at some stage (usually as a child) and many people have cold sores. The virus does not completely go after you have chickenpox or a cold sore. Some virus particles remain dormant (inactive) in the nerve roots. They do no harm there, and cause no symptoms. For reasons that are not clear, the virus may begin to multiply again (re-activate). This is often many months or years later. In some cases, the re-activated' virus is thought to cause inflammation around the facial nerve to cause Bell's palsy.

What are the symptoms of Bell's palsy?
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.

. Most cases are painless or cause just a mild ache. However, some people develop some pain near the ear which can last for a few days.
. 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.

Does Bell's palsy affect the brain or other parts of the body?
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.

For example:

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.

With tumours, the symptoms usually develop slowly - over weeks or months. This is unlike a Bell's palsy when symptoms develop quickly - often 'overnight'.

Conditions such as sarcoidosis and Lyme disease tend to cause various other symptoms in addition to nerve palsies.

In particular, Bell's palsy is uncommon in children under 10 years old. Other conditions should be carefully ruled out in children who develop facial weakness.

How does Bell's palsy progress?

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.
However, some tests are done in some situations. For example, in areas where Lyme disease is common (due to tick bites), then tests to rule out Lyme disease may be done. This is because a facial weakness is, rarely, the first indication of Lyme disease. Other tests may be advised if the diagnosis is not clear-cut.

What is the treatment for Bell's palsy?
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.

The general conclusion of an earlier Cochrane analysis was that the use of steroids and aciclovir was neither safe nor evidence based, although a recent multicentre, randomised, placebo-controlled trial of valacyclovir and prednisolone treatment showed that the rate of patient recovery among those treated with valacyclovir was significantly better than the rate among those treated with prednisolone alone.

In the meantime, a reasonable course of action is to use steroids in early cases, always use aciclovir for Ramsay-Hunt syndrome and consider referral or discuss all non-straightforward cases with neurology or ENT department, who can offer appropriate follow up.

· 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.

71% of untreated patients with idiopathic non progressive Bell's palsy recover completely (84% have near-normal function) usually within a few weeks.

Poor prognostic features:
· 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

Eye protection
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.

Therefore, you doctor may advise one or more of the following until the eyelids and tear production recover:

. 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.
An option is to tape the upper and lower lid together when you are asleep. Other procedures are sometimes done to keep the eye shut until the eyelids recover.

If the facial weakness does not recover
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.

Injections of botulism toxin ('Botox®') may help if spasm develops in the facial muscles.
Various surgical techniques can help with the cosmetic appearance.

Will it happen again?
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.

. Weakness of the muscles of facial expression and eye closure.
. Face sags and is drawn across to opposite side on smiling.
. Voluntary eye closure may not be possible and can produce damage to conjunctiva and cornea.
· 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.

The most common system used for describing the degree of paralysis is the House-Brackmann scale, where 1 is normal power and 6 is total paralysis. It is important to identify whether the patient has an upper motor neurone (UMN) or lower motor neurone (LMN) lesion to assist in identifying cause.

· In a LMN lesion the patient can't wrinkle their forehead - the final common pathway to the muscles is destroyed. Lesion must be either in the pons, or outside the brainstem (posterior fossa, bony canal, middle ear or outside skull).
· 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.

CVA's (cerebro vascular accident) usually weaken voluntary movement often sparing involuntary movements (e.g. spontaneous smiling). The much rarer selective loss of emotional movement is called mimic paralysis and is usually due to a frontal or thalamic lesion.

Characteristic features
Acute LMN palsy
Acute LMN palsy can present at any age but most frequently seen at 20-50 years affecting both sexes equally. Incidence is around 30 cases per 100,000 per year, slightly higher in pregnant women (45 per 100,000). There is usually a rapid onset of unilateral facial paralysis.

Aching pain below ear or in mastoid area is also common and may suggests middle ear or herpetic cause if severe. There may be hyperacusis, and patients with lesions proximal to the geniculate ganglion may be


· 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.
Treatment of facial palsy by Chinese herbs.
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
SYMPTOMS The following are the most common symptoms of Bell's palsy.

However, each individual may experience symptoms differently. Symptoms may include:
. 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

The symptoms of Bell's palsy may resemble other conditions or medical problems. Always consult your physician for a diagnosis.

DESCRIPTION Bell's palsy describes an unexplained weakness or paralysis of the muscles on one side of the face. Afflicted individuals may be unable to close the eye on the affected side of the face, and may also experience tearing, drooling, and hypersensitive hearing.

CLINICAL SUCCESS IN CHINA Chinese herbal doctors have reported some successful applications of these herbal combinations. During observation on 132 patients receiving treatment with herbal remedy, 118 cases were judged as healing (full recovery and symptom free), 11 cases others significant improvement. Physicians judged the clinical efficacy to be good or excellent in 97.7%.

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.

Authoritative Oriented Recipes: All these well chosen herbal combinations source from experienced and authoritative experts, and have been most commonly recognized by the practitioners in this field. When you choose a herbal remedy there are two important things among your concerns: a good recipe and a correct way to cook it. A good recipe is half the good results.

HERBS OF CHOICE Herbs are often used in combinations when combating an illness. Some of the most frequently used herbs are listed below. These nine herbs were picked up from different herbal combinations and are not meant to form a recipe.

1 - Radix Angelicae Pubescentis
2 - Radix Gentianae Macrophyllae
3 - Concha Haliotidis
4 - Ramulus Uncariae cum Uncis
5 - Rhizoma Ligustici Chuanxiong
6 - Radix Bupleuri
7 - Radix Angelicae Sinensis
8 - Fructus Tribuli
9 - Radix Angelicae Dahuricae

Safe and Side Effect Free: All these herbs have been being used in China for thousands of years, and have been proven to be safe. In fact most Chinese herbs are tonics without side effects. What important is that experienced practitioners should know how to use herbs to avoid possible side effects.

Acupuncture would help peoples suffered from facial palsy
We have the herbs and willing to help any one suffering from Facial Nerve Palsy
Just ask for it.