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14-September-2008 18:02:35 - Bell's palsy Bell's Palsy Classification and external resources ICD-10 G51.0 ICD-9 351.0 DiseasesDB 1303 MedlinePlus 000773 eMedicine emerg/56 MeSH D020330 Bell's palsy is a paralysis of the facial nerve resulting in inability to control facial muscles on the affected side. Several conditions can cause a facial paralysis, e.g., brain tumor, stroke, and Lyme disease. However, if no specific cause can be identified, the condition is known as Bell's Palsy. Named after Scottish anatomist Charles Bell, who first described it, Bell's palsy is the most common acute mononeuropathy disease involving only one nerve, and is the most common cause of acute facial nerve paralysis. Bell's palsy is defined as an idiopathic unilateral facial nerve paralysis, usually self-limiting. The trademark is rapid onset of partial or complete palsy, usually in a single day. It is thought that an inflammatory condition leads to swelling of the facial nerve nervus facialis. The nerve travels through the skull in a narrow bone canal beneath the ear. Nerve swelling and compression in the narrow bone canal are thought to lead to nerve inhibition, damage or death. No readily identifiable cause for Bell's palsy has been found, but clinical and experimental evidence suggests herpes simplex type 1 infection may play a role. Doctors may prescribe anti-inflammatory and anti-viral drugs. Early treatment is necessary for the drug therapy to have effect. The effect of treatment is still controversial. Most people recover spontaneously and achieve near-normal functions. Many show signs of improvement as early as 10 days after the onset, even without treatment. Often the eye in the affected side cannot be closed. The eye must be protected from drying up, or the cornea may be permanently damaged resulting in impaired vision. Former Canadian Prime Minister Jean Chrétien acquired Bell's palsy in his youth. Former Canadian Prime Minister Jean Chrétien acquired Bell's palsy in his youth. Contents 1 Investigation 2 Diagnosis 3 Pathology 4 Virus reactivation 5 Other symptoms 6 Alternative medicine 7 Treatment 8 Recovery 9 Complications 10 See also 11 References 12 External links Investigation Bell's palsy or facial palsy is characterized by facial drooping on the affected half, due to malfunction of the facial nerve VII cranial nerve, which controls the muscles of the face. Facial palsy is typified by inability to control movement in the facial muscles. The paralysis is of the infranuclear/lower motor neuron type. The facial nerves control a number of functions, such as blinking and closing the eyes, smiling, frowning, lacrimation, and salivation. They also innervate the stapedial stapes muscles of the middle ear and carry taste sensations from the anterior two thirds of the tongue. Clinicians should determine whether the forehead muscles are spared. Due to an anatomical peculiarity, forehead muscles receive innervation from both sides of the brain. The forehead can therefore still be wrinkled by a patient whose facial palsy is caused by a problem in one of the hemispheres of the brain central facial palsy. If the problem resides in the facial nerve itself peripheral palsy all nerve signals are lost, including to the forehead. One disease that may be difficult to exclude in the differential diagnosis is involvement of the facial nerve in infections with the herpes zoster virus. The major differences in this condition are the presence of small blisters, or vesicles, of the external ear and hearing disturbances, but these findings may occasionally be lacking zoster sine herpete. Lyme disease may produce the typical palsy, and may be easily diagnosed by looking for Lyme-specific antibodies in the blood. In endemic areas Lyme disease may be the most common cause of facial palsy. The degree of nerve damage can be assessed using the House-Brackman Score. Diagnosis Bell's palsy is a diagnosis of exclusion; by elimination of other reasonable possibilities. Therefore, by definition, no specific cause can be ascertained. Bell's palsy is commonly referred to as idiopathic or cryptogenic, meaning that it is due to unknown causes. Being a residual diagnostic category, the Bell's Palsy diagnosis likely spans different conditions which our current level of medical knowledge cannot distinguish. This may inject fundamental uncertainty into the discussion below of etiology, treatment options, recovery patterns etc. See also the section below on Other symptoms. Studies1 show that a large number of patients 45% are not referred to a specialist, which suggests that Bell's palsy is considered by physicians to be a straightforward diagnosis that is easy to manage. A significant number of cases are misdiagnosed ibid.. This is unsurprising from a diagnosis of exclusion, which depends on a thorough investigation. Pathology It is thought that as a result of inflammation of the facial nerve, pressure is produced on the nerve where it exits the skull within its bony canal, blocking the transmission of neural signals or damaging the nerve. Patients with facial palsy for which an underlying cause can be found are not considered to have Bell's palsy per se. Possible causes include tumor, meningitis, stroke, diabetes mellitus, head trauma and inflammatory diseases of the cranial nerves sarcoidosis, brucellosis, etc.. In these conditions, the neurologic findings are rarely restricted to the facial nerve. Babies can be born with facial palsy2. In a few cases, bilateral facial palsy has been associated with acute HIV infection. In some research3 the herpes simplex virus type 1 HSV-1 was identified in a majority of cases diagnosed as Bell's palsy. This has given hope for anti-inflammatory and anti-viral drug therapy prednisone and acyclovir. Other research4 however, identifies HSV-1 in only 31 cases 18 percent, herpes zoster zoster sine herpete in 45 cases 26 percent in a total of 176 cases clinically diagnosed as Bell's Palsy. That infection with herpes simplex virus should play a major role in cases diagnosed as Bell's palsy therefore remains a hypothesis that requires further research. In addition, the herpes simplex virus type 1 HSV-1 infection is associated with demyelination of nerves. This nerve damage mechanism is different from the above mentioned - that oedema, swelling and compression of the nerve in the narrow bone canal is responsible for nerve damage. Demyelination may not even be directly caused by the virus, but by an unknown immune system response. The quote below captures this hypothesis and the implication for other types of treatment: It is also possible that HSV-1 replication itself is not responsible for the damage to the facial nerves and that inhibition of HSV-1 replication by acyclovir does not prevent the progression of nerve dysfunction. Because the demyelination of facial nerves caused by HSV-1 reactivation, via an unknown immune response, is implicated in the pathogenesis of HSV-1-induced facial palsy, a new strategy of treatment to inhibit such an immune reaction may be effective.4 The Bell's smile is characterized by an asymmetry caused by paralysis of one side of the face. The Bell's smile is characterized by an asymmetry caused by paralysis of one side of the face. Virus reactivation Some viruses are thought to establish a persistent or latent infection without symptoms, e.g. the Zoster virus of the face5 and Epstein-Barr viruses, both of the herpes family. Reactivation of an existing dormant viral infection has been suggested4 as cause behind the acute Bell's palsy. Studies6 suggest that this new activation could be preceded by trauma, environmental factors, and metabolic or emotional disorders, thus suggesting that stress - emotional stress, environmental stress e.g. cold, physical stress e.g. trauma - in short, a host of different conditions, may trigger reactivation. Other symptoms Although defined as a mononeuritis involving only one nerve, patients diagnosed with Bell's palsy may have myriad neurological symptoms including facial tingling, moderate or severe headache/neck pain, memory problems, balance problems, ipsilateral limb paresthesias, ipsilateral limb weakness, and a sense of clumsiness that are unexplained by facial nerve dysfunction.1 This is yet an enigmatic facet of this condition. Alternative medicine In traditional Chinese medicine, Bell's palsy is attributed to exposure to wind - more specifically due to wind-cold attacking the Shaoyang liver, gall bladder and Yangming stomach, large intestine channels as well as the tendons and muscles. This is thought to result in an obstruction of Qi vital energy and blood in these areas that leads to malnourishment of the tendons and muscles and thus a propensity for the facial muscles to become lax or paralyzed7 Formal studies of the effects of acupuncture on Bell's Palsy are inconclusive see below, Treatment. Treatment Treatment of Bell's palsy is a matter of controversy. Two Cochrane reviews from 2004 underlined the need for larger, properly designed clinical trials to evaluate antiviral drugs8 or corticosteroids9 for Bell's palsy. The effect of treatment is difficult to evaluate experimentally because spontaneous recovery without any treatment is common. In patients presenting with incomplete facial palsy, where the prognosis for recovery is very good, treatment may be unnecessary. Patients presenting with complete paralysis, marked by an inability to close the eyes and mouth on the involved side, are usually treated. Early treatment within 3 days after the onset seems to be necessary for therapy to be effective.10 Prednisolone, a corticosteroid, if used early in treatment of Bell's palsy, significantly improves the chances of complete recovery at 3 and 9 months when compared to treatment with the anti-viral drug acyclovir or no treatment at all.11 The possible link between Bell's palsy and the herpes simplex and varicella zoster virus has led to the prescription of anti-viral medications such as acyclovir or valaciclovir to patients with unexplained facial palsy. Recently 2007, a large randomized clinical trial reported no additional benefit from acyclovir beyond that from prednisolone alone.11 The efficacy of acupuncture remains unknown because the available studies are of low quality poor primary study design or inadequate reporting practices.12 Surgical procedures to decompress the facial nerve have been attempted, but have not been proven beneficial. A 2005 practice parameter from the American Academy of Neurology states that corticosteroids are safe and probably effective, and that acyclovir is safe and possibly effective.13 Physiotherapy is also a vital part of Bell's palsy since it is a nerologic condition. Facial kabat techniques and criostimulation along with exercises based on facial mimicry have shown good results in clinical practicecitation needed. Recovery Even without any treatment, Bell's palsy tends to carry a good prognosis. In a 1982 study14, when no treatment was available, of 1,011 patients, 85% showed first signs of recovery within 3 weeks after onset. For the other 15%, recovery occurred 3-6 months later. After a follow-up of at least 1 year or until restoration, complete recovery had occurred in more than two thirds 71% of all patients. Recovery was judged moderate in 12% and poor in only 4% of patients. Another study15 finds that incomplete palsies disappear entirely, nearly always in the course of one month. The patients who regain movement within the first two weeks nearly always remit entirely. When remission does not occur until the third week or later, a significantly greater part of the patients develop sequelae. A third study6 found a better prognosis for young patients, aged below 10 years old, while the patients over 61 years old presented a worse prognosis. Complications Major complications of the condition are chronic loss of taste ageusia, chronic facial spasm and corneal infections. To prevent the latter, the eyes may be protected by covers, or taped shut during sleep and for rest periods, and tear-like eye drops or eye ointments may be recommended, especially for cases with complete paralysis. Where the eye does not close completely, the reflex is also affected; great care should be taken to protect the eye from injury. Another complication can occur in case of incomplete or erroneous regeneration of the damaged facial nerve. The nerve can be thought of as a bundle of smaller individual nerve connections which branch out to their proper destinations. During regrowth, nerves are generally able to track the original path to the right destination - but some nerves may sidetrack leading to a condition known as synkinesis. For instance, regrowth of nerves controlling muscles attached to the eye may sidetrack and also regrow connections reaching the muscles of the mouth. In this way, movement of one also affects the other. For example, when the person closes the eye, the corner of the mouth lifts involuntarily. In addition, around 6%citation needed of patients exhibit crocodile tear syndrome on recovery, where they will shed tears while eating. This is thought to be due to faulty regeneration of the facial nerve, a branch of which controls the lacrimal and salivary glands. See also List of famous people with Bell's Palsy References ^ a b Morris AM, Deeks SL, Hill MD, et al 2002. Annualized incidence and spectrum of illness from an outbreak investigation of Bell's palsy. Neuroepidemiology 21 5: 255-61. PMID 12207155. ^ - MedlinePlus Medical Encyclopedia: Facial nerve palsy due to birth trauma retrieved 10 September 2008 ^ Murakami S, Mizobuchi M, Nakashiro Y, Doi T, Hato N, Yanagihara N 1996. Bell palsy and herpes simplex virus: identification of viral DNA in endoneurial fluid and muscle. Ann. Intern. Med. 124 1 Pt 1: 27-30. PMID 7503474. ^ a b c Furuta Y, Ohtani F, Chida E, Mesuda Y, Fukuda S, Inuyama Y 2001. Herpes simplex virus type 1 reactivation and antiviral therapy in patients with acute peripheral facial palsy. Auris Nasus Larynx 28 Suppl: S13-7. PMID 11683332. ^ Facial Nerve Problems and Bell's Palsy Information on MedicineNet.com ^ a b Kasse et al. 2003 Clinical data and prognosis in 1521 cases of Bell's palsy. International Congress Series 2003 Issue Vol.1240 Page no. 641-647 ISSN 05315131 page 646 ^ Pao, Fay-Meling von Moltke. July 2005. Bell's Palsy Online newsletter. Points, July 2005, Vol. 3, No. 7, via accupuncture.com. Retrieved on 2007-09-06. ^ Allen D, Dunn L 2004. Aciclovir or valaciclovir for Bell's palsy idiopathic facial paralysis. Cochrane Database Syst Rev 3: CD001869. doi:10.1002/14651858.CD001869.pub2. PMID 15266457. ^ Salinas RA, Alvarez G, Ferreira J 2004. Corticosteroids for Bell's palsy idiopathic facial paralysis. Cochrane Database Syst Rev 4: CD001942. doi:10.1002/14651858.CD001942.pub2. PMID 15495021. ^ Hato N, Matsumoto S, Kisaki H, et al November 2003. Efficacy of early treatment of Bell's palsy with oral acyclovir and prednisolone. Otol. Neurotol. 24 6: 948-51. PMID 14600480. ^ a b Sullivan FM, Swan IR, Donnan PT, et al October 2007. Early treatment with prednisolone or acyclovir in Bell's palsy. N. Engl. J. Med. 357 16: 1598-607. doi:10.1056/NEJMoa072006. PMID 17942873. ^ He L, Zhou MK, Zhou D, et al 2007. Acupuncture for Bell's palsy. Cochrane Database Syst Rev 4: CD002914. doi:10.1002/14651858.CD002914.pub3. PMID 17943775. ^ Ahmed A 2005. When is facial paralysis Bell palsy? Current diagnosis and treatment. Cleve Clin J Med 72 5: 398-401, 405. PMID 15929453. ^ Peitersen E 1982. The natural history of Bell's palsy. Am J Otol 4 2: 107-11. PMID 7148998. quoted in Roob G, Fazekas F, Hartung HP 1999. Peripheral facial palsy: etiology, diagnosis and treatment. Eur. Neurol. 41 1: 3-9. PMID 9885321. ^ Peitersen E, Andersen P 1966. Spontaneous course of 220 peripheral non-traumatic facial palsies. Acta Otolaryngol.: Suppl 224:296+. PMID 6011525. External links Bell's palsy at the Open Directory Project v d e Nervous system pathology, primarily PNS G50-G99, 350-359 Nerve, nerve root and plexus disorders Cranial nerve disease V Trigeminal neuralgia - VII Facial nerve paralysis, Bell's palsy, Melkersson-Rosenthal syndrome, Central seven - XI Accessory nerve disorder Radiculopathy, plexopathy Brachial plexus lesion - Thoracic outlet syndrome - Phantom limb Mono- neuropathy upper limb Carpal tunnel syndrome, Ulnar nerve entrapment, Radial neuropathy lower limb Meralgia paraesthetica, Tarsal tunnel syndrome, Morton's neuroma Causalgia - Mononeuritis multiplex Polyneuropathies HMSN Charcot-Marie-Tooth disease - Dejerine Sottas syndrome - Refsum's disease Polyradiculoneuropathy autoimmune Guillain-Barré syndrome, Chronic inflammatory demyelinating polyneuropathy - Alcoholic polyneuropathy Diseases of muscle myopathy/ neuromuscular disease Neuromuscular junction disease autoimmune Myasthenia gravis, Lambert-Eaton myasthenic syndrome Muscular dystrophy Congenital - dystrophin Becker's, Duchenne - Distal - Emery-Dreifuss - Facioscapulohumeral - Limb-girdle muscular dystrophy - Myotonic - Oculopharyngeal Myotonia Myotonic dystrophy - Myotonia congenita - Thomsen disease - Neuromyotonia - Paramyotonia congenita Congenital myopathy Bethlem myopathy - Central core disease - Centronuclear myopathy - Nemaline myopathy - Zaspopathy Mitochondrial myopathy MELAS - MERRF - KSS - PEO Periodic paralysis Hypokalemic - Hyperkalemic Dysautonomia/ Autonomic neuropathy HSAN Familial dysautonomia - Horner's syndrome - Multiple system atrophy Shy-Drager syndrome, Olivopontocerebellar atrophy Retrieved from http://en..org/wiki/Bell%27s_palsy Categories: Neurological disorders | OtolaryngologyHidden categories: All articles with statements | Articles with statements since May 2008 | Articles with statements since December 2007 Views Article Discussion this page History Personal tools Log in / create account Navigation Main page Contents Featured content Current events Random article Search Go Search Interaction Community portal Recent changes Contact Donate to Help Toolbox What links here Related changes Upload file Special pages Printable version Permanent link Cite this page Languages العربية Català Dansk Deutsch Español Français Bahasa Indonesia Nederlands 日本語 Polski Suomi Svenska Tiếng Việt Türkçe This page was last modified on 12 September 2008, at 04:09
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