Bells palsy

Member of Second Group

ANDRIANI AGUSTIN 6130014002
BAHTIAR NAWABIG H 6130014007
CLAUDIA NARINDRA R P 6130014012
HESSTY ROCHENDAH ONJIAH 6130014017
ANYDHIA FITRIANA AFIUDDIN 6130014022
RAHMANIAH ULFAH 6130014027
MAYA AYU ELFRIDA 6130014032
LAILA AL ISTIGHFARA 6130014037
LINTAN KURNIA FARIZQI 6130014042
APRINA TRIMURTININGRUM 6130014047
 Scenario
A 20-year-old woman came in a poly general practitioner complaining of numbness on the cheek
and right ear. The night before the complaint arose the patient told to go home late at night
riding a motorcycle after doing group work. Then sleep on the floor using a fan that leads
continuously to his face. Wake up sleeping patient looking in the mirror, face asymmetrical to
the left when smiling. The patient also complains that the right eyelid can not close, the right
eye nerocos out the tears and the pain behind the right ear. Patients complain difficult when
rinsing and drinking water with a straw. No disfunction talk. no weakness left limb member.
Vital sign is normal.

PHYSICAL EXAMINATION
Vital Sign: GCS 456
TD 120/70 mmHg
A strong regular 88x / minute pulse
RR 24 regularly
Inspection: Head-neck within normal limits
Thorax is within normal limits
Abdomen within normal limits
Lakrimation within normal limits
Disfunction of Speaking (-) weakness of the extremity (-)
Anatomy N.VII (N.Fascialis)

Nucleus facial for somatomotor

nerves

Superior salivatorius nucleus for

viseromotor nerve
(parasympathetic)

The solitarius nucleus for the

viserosensory nerve

Somatosensory nucleus

4
 Examination Of Ramsay Hunt
Syndrome and Chronic Lyme Disease
Ramsay Hunt Syndrome
Nerve 7 motor examination
Tuning fork
Audiometry
Tympanometry
Schimer Test
Freyss System
PCR
Chronic Lyme Disease
Enzyme immunoassay (EIA)
Indirect immunofluorescence (IFA)
 Pathophysiology and examination of
cerebello pontiangle
Serebelopontin / cerebellopontine
angle (CPA), which is a shaped region
triangle on the posterior posterior fossa
by the temporal bone, the cerebellum
and the pons. In this area there is often
a period abnormal which is then
referred to as tumor CPA, tumors that
grow in the area this can cause various
symptoms serious neurological death
even if tumor continues to grow
enlarged and suppress brain stem.
Symptoms are often the case ipsilateral
hearing loss of hypestheses on the face
and disorder.
Audiology Test :
Pure tone audimetry and speech
audimetry are the first checks to be
performed. Then the test can be
continued with an acoustic reflex
threshold test and an Auditory brainstem
response. 4 Vocabulary and Potential
Vocabulary Vocabulary (VEMP) tests
can be performed to determine if
damage occurs in the inferior or superior
parts of the vestibular nerve. VEMP can
also be used to find out how
vestibulospinal reflexes in patients with
CPA tumors
 Physical Examination are :
Neurological examination V
(trigeminal nerve)
1. Sensory
Modalities that must be
investigated include pain,
heat, cold and touch we do
according to the sensory
pattern trigeminal nerve.
2. Motoric
Patients are told to bite
his teeth as hard as possible
and the two examiner's hands
palpate maseter muscle
contraction.
Neurological Examination (Facialis
nerve)
1. Inspection, facial asymmetry and
abnormal movements (facial tic,
grimacing, tetanus seizures /
rhesus sardonicus, tremors,
etc.)
2. the patient is asked to raise
eyebrows, close his eyes, open
his eyes, show his teeth, whistle
and pull the corners of his
mouth down
3. Special sensory (tasting 2/3 front
of the tongue)
This examination requires
substances that have a sweet
taste, bitter, salty, sour.
 Physical Examination found are :
A careful examination of the head, ear, eyes, nose and mouth should be
performed in all patients with facial paralysis.
1. Weakness or paralysis involving the facial nerve (N VII) results in one-
sided (unilateral) facial (unilateral) weakness. In the UMN lesion (supra
nuclear lesion / above the facial nucleus in the pons), the upper face
does not experience paralysis. This is due to the orbicularis, frontalist
and korrugator muscles, bilaterally conserved by the corticobulbaris
nerve. When the patient is asked to raise an eyebrow, the side of the
paralyzed lobe is flat.
2. In the initial phase, patients may also report an increase in salivation.

Moreover, if the patient complained also about the existence of limb paralysis
(hemiparesis), disorder balance (ataxia), nystagmus, diplopia, or other cranial
nerve paresis, most likely NOT Bell's palsy.
 Grading system of Bell's palsy
(House and Brackmann )
1. Grade I is a normal facial function.
2. Grade II mild dysfunction.
Its characteristics are as follows:
a. Minor weakness when inspected in detail.
b. Mild cosmetics may occur.
c. Normal symmetry at rest.
d. The movement of the forehead is slightly to good.
e. Perfect eye shading can be done with minimal effort. f.
Little oral asymmetry can be found.
 Grading system of Bell's palsy
(House and Brackmann )
3. Grade III is a moderate dysfunction, with the following characteristics:
a. The asymmetry of both sides is obvious, minimal weakness.
b. The presence of sinkinesis, hemifacial contractures or spasms can be found.
c. Normal symmetry at rest.
d. Movement of the forehead slightly to moderate.
e. Perfect eye shading can be done with effort.
f. A little weak mouth movement with maximum effort.
4. Grade IV is moderate to severe dysfunction, with the signature as follows:
a. Weakness and asymmetry are clearly visible.
b. Normal symmetry at rest.
c. There is no movement of the forehead.
d. Eyes do not close perfectly.
e. Asymmetric mouth is done with maximum effort.
 Grading system of Bell's palsy
(House and Brackmann )
5. Grade V is a severe dysfunction. Its
characteristics are as follows:
a. Only a few moves can be done.
b. Asymmetry is also present at rest.
c. There is no movement on the forehead.
d. Eyes closed imperfectly.
e. Movement of the mouth only slightly.
6. Grade VI is total paralysis. Conditions are:
a. Broad asymmetry.
b. No facial muscle movement.
 Treatment of Bell's palsy
Medical, surgery, and physical therapy. All
treatments are aimed at reducing inflammation,
edema and nerve compression (Axelsson
2013).
 Treatment of Bell's palsy
1. Initial treatment :
a. Corticosteroids (Prednisone), dose: 1 mg / kg or 60 mg / day for 6 days,
followed by a gradual decrease in total for 10 days.
b. Steroids and acyclovir (with prednisone) may be effective for the treatment
of Bells' palsy (American Academy Neurology / AAN, 2011).
c. Steroids are potentially effective and improve cranial nerve function
improvements, if given at early onset (ANN, 2012).
d. In the absence of renal gap impairment, antiviral (Acyclovir) may be given at
400 oral doses 5 times daily for 7-10 days. If varicella zoster virus is
suspected, high dose 800 mg orally 5 times / day.
2. Protect the eyes Eye care: topical ocular lubrication with artificial tears
(artificial tear drops) can prevent corneal exposure. (see the dry eye section)
3. Physiotherapy or acupuncture can be performed after passing the acute
phase (+/- 2 weeks).

* Follow-up Plan Re-examination of the facial nerve function to monitor

repair after treatment.
 Complication of Bell's palsy
Unilateral ocular complications in the initial phase include:
1. Lagoftalmus (inability to close the eyes in total)
2. Decreased secretion of tears
3. Both of the above can cause corneal exposure, corneal erosion, infection and corneal ulceration
4. Upper eyelid retraction
Advanced ocular manifestations :
1. Lightweight: contracture of facial muscle, palpebral cleft widening.
2. Regeneration of facial nerve grains with motor sinkinesis.
3. Autonomous syncinesis (tears of crocodiles, in the form of dripping tears while chewing).
4. Two thirds of patients complain of tears. This occurs because of the decrease in orbicularis okuli
function in assisting tear excretion.
Auricular pain posterior Half of patients with Bells' palsy complain of posterior
auricular pain.
Sputtering disorders Although only one-third of patients report taste disorder, about
80% of patients show a decrease in taste taste. The likelihood of the patient fails to
recognize the decrease of taste, because the other side of the tongue is not
disturbed. The initial healing tasting indicates complete healing
 Prognosis of` Bell's palsy
The prognosis of bell's palsy depends on:
The prognosis is generally good, the condition is controlled with
maintenance treatment. The healing occurred within 3 weeks in 85% of
patients. May leave sequelae (sekuale) of unilateral or contralateral facial
weakness, sinkinesis, haemifacial spasm, and sometimes recurrence,
requiring further evaluation and referral. Type of degree, partial paralysis
(incomplete/ complete), has a better prognosis.
Patient age: children have a better prognosis than adults
Bell's palsy with grading of house-brackmann degrees <2 can heal
perfectly, whereas in house-brackmann degrees> 4 there is often a
permanent deformity of the face.
Recurrence increases in patients with a history of Bell's palsy in the family
(herpes simplek)
 Reference

1. Rucker JC. Cranial Neuropathy. In Darrof RB et al (Eds).

Bradleys Neurology in Clinical Practice. Vol 1:
Principles of Diagnosis and Management. 6th ed.
Elsevier, Philadelphia, 2012:1754-1757. (Rucker, 2012)
2. Gooch C, Fatimi T. Peripheral Neuropathy. In Brust
JCM (Ed). Current Diagnosis and Treatment in
Neurology. McGraw Hill, New York, 2007:286-288.
(Gooch & Fatimi, 2007)
3. Taylor, D.C. Keegan, M. Bells Palsy Medication.
Medscape.
4. Medscape: Empiric Therapy Regimens.