Sravani Bells Project Report

7/31/2019 Sravani Bells Project Report

1/81

INTRODUCTION

Bells palsy, or idiopathic facial paralysis, is a form offacial Paralysis resulting from dysfunction cranial nerve

VII (the facial nerve) that result in the inability to control

facial muscles on the affected side. It is named after

Scottish anatomist CHARLES BELL.

Bells palsy is the most common acute

mononeuropathy and is the common cause acute facial

nerve paralysis. Several conditions can cause facial

paralysis Eg: brain tumor, stroke, Lyme disease.

Statistics, both males and females are equally affected

and recovered. The annual incidence of Bells palsy isabout 20 per 100,000 population and incidence increases

with age. It affects approximately 1 person in 65 during life

time. Familial inheritance has been found 4-14% of cases.

It is three times more likely to found in pregnant than non-

pregnant women. It is four times more likely occur in

diabetics than the general population.

1


2/81

Bells palsy is diagnosed by bells phenomenon. A

warning sign may be neck pain or pain in or behind the earprior to palsy, but it is not usually recognized in first time

cases.

Treatment of Bells palsy is variable, ranging from

observation to surgical decompression. Physiotherapy playsan important role in bells palsy ,electrical stimulation to

stimulate muscles and to maintain its properties, massage

therapy ,facial exercise to improve strength and co-

ordination ,and finally home program is given for

progression of treatment this may cause recovery from

bells palsy.

Approximately 50% of Bells palsy patients will have

essentially complete recoveries in a short time another 35%

will have good recoveries in less than a year.

2


3/81

ANATOMY

Facial Nerve:

This is the seventh cranial nerve

It is the nerve of second brachial arch.

Nuclei:

The fibers of this nerve arise from four nuclei, situated in

the lower part of the pons.

a) Motor Nucleus:

It gives special visceral efferent fibers to the musclesresponsible for facial expression and for evaluation of

hyoid bone.

b).Superior Salivatory Nucleus:

It gives general visceral efferent fibers.

(These fibers also arises from motor nucleus) are

secretomotor to the submandibular and sublingual salivaryglans, the lacrimal glands and the glands of the nose, the

palate and pharynx.

3


4/81

c).Nucleus Tractus Solitarius:

It gives special visceral afferent fibers that carry taste

sensations from the anterior 2/3rd of the tongue and from

the palate.

d).Lacrimatory Nucleus (Parasympathetic):

It gives general somaticafferent fibers innervate a

part of skin of the ear.

Course and relations:

The facial nerve is attached to the brain stem by two roots.

1) Motor 2) Sensory

> The sensory root is also called the Nervous

Intermedius.

> The two roots of the facial nerve are attached to the

lateral part of the lower border of the pons.> The two roots run laterally and forwards to reach the

internal acoustic meatus.

> In the acoustic meatus the motor root lies in the

groove with the sensory root intervening.

> At the bottom of the meatus the two roots (Sensory

& Motor) fuse to form a single trunk, which lies in the

pectrous temporal bone.> With in the canal the course of the nerve will be

divided into 3 parts by two bends.

4


5/81

> The first part is directed laterally above the

vestibule. The second part runs backwards in the medial

wall of the middle ear, above the promontory.

> The third part is behind the promontory.> The first bed is present anterior-superior part of the

promontory and is also called as genu. The second bend

lies between the promontory and the auditus to the mastoid

antrum.

The facial nerve leaves the skull by passing through

the stylomastoid foramen.

IN this extra cranial course it crosses the lateral sideof the base of the styloid process enters the

posterior-medial surface of the parotid gland and

runs forward through the gland.

Behind the neck of the mandible it divides into 5

terminal branches which emerge along the anterior

border of the parotid gland.

Branches & Distribution:

a) With in the facial canal:

1) Greater petrosal nerve: It arises from the geniculate

ganglion of the facial nerve carries gustatory and

parasympathetic fibers.

2) The nerve to the stapedius: Arises opposite the

pyramid of the middle ear and supplies the stapedius

muscle.3) The chorda tympani: Arises in the vertical part of

the facial canal, and it supplies anterior 2/3rd of the tongue.

5


6/81

b) At it exists from stylomastoid foramen:

1) Posterior auricular nerve: Arises just below the

stylomastoid foramen and supplies the auricularis posterior.

The occipitalis and the intrinsic muscles of the back of theauricle.

2) The digastric branch: Arises just below the

stylomastoid foramen and supplies, the posterior belly of

diagsric muscle.

3) Stylomastoid branch: Arises just below the

stylomastoid foramen and supplies stylomastoid muscle.

c) Terminal branches: With in the parotid glands.1) Temporal branch: Supplies auricularis anterior.

The intrinsic muscles on the lateral side of the ear.

Frontalis

Orbicularis occuli

Corrugator supercili

2) Zygomatic branch: Supplies the orbicularis occuli.3) Buccal Branch: Supplies the buccinator muscle

elevators of the upper lip and the orbicularis oris.

4) Mandibular branch: Supplies the muscles of lower

lip and chin.

5) Cervical Branch: Supplies platysma.

Communicating branchs: For effective coordination

between the movements of the 1st, 2nd, 3rd branchialarches.

6


7/81

MYOLOGY

Facial Muscles:

Epicranial Musculature:

1) Occipitalis

Origin: Occipital bone and mastoid process.

Insertion: Galea aponeurotica

Action: Moves scalp backwards.

2) Frontalis

Origin: Galea aponeurotica.

Insertion: Skin of eyebrow.

Action: Wrinkles on forehead and elevates the

eyebrows.

Orbital Musculature:

Orbicularis Occuli:Origin: Bones of medial orbit.

Insertion: Tissue of eyelid.

Action: Closes eyes.

1) Corrugator supercilli

Origin: Fascia above eyebrow.

Insertion: Root of the nose.Action: Draws eyebrows forwards midline.

7


8/81

Nasal Musculature:

1) Nasal Procerus

Origin: Fascia over the nasal bone

Insertion: Into the skin immediately above theridge of the nose.

Action: Horizontal wrinkles over the nose.

Nasalis:

Its has two parts

a) Compressor naris b) Dilator Naris.

a) Compressor Naris

Origin: Lateral Margin of anterior nasal aperture

Insertion: Continues with the same fiber from the

opposite side.

Action: Compresses the anterior apertures

b) Dilator naris

Origin: Lateral margin of the anterior nasalaperture

Insertion: Ala of nose

Action: Dilates anterior nasal aperture

Depressor septi nasi

Origin: Upper incisive fossa

Insertion: Lower and anterior part of the nasal septumAction: Depression of the nasal septum

8


9/81

Auricular Musculature:

1) Rudimentary

2) Auricularis

a) Superiorb) Anterior

c) Posterior

Oral musculature:

a) Superficial

b) Deep

a) Superficial:

1. Levator labi superiorisOrigin: Upper maxilla and zygomatic bone

Insertion: Orbicularis oris and skin above lips

Action: Elevates upper lip

2. Levator labi superioris aleqi nasi

Origin: Frontal process of maxilla

Insertion: Skin of upper lip

Action: Elevation of upper lip3. Orbicularis oris

Origin: Fascia surrounding lips

Insertion: Mucosa of lips

Action: Closes and purses the lips

4. Zygomatis major &minor

Origin: Anterior surface of zygomaInsertion: Superficial striata of orbicularis oris

Action: Elevates corner of mouth

9


10/81

5. Depressor labi inferioris

Origin: Anterior part of oblique line of mandible

Insertion: Into lower lip

Action: Depresses the lower lip

6. Depressor anguli oris

Origin: Posterior part of oblique line of mandible

Insertion: Lower lip mouth

Action: Depresses the lower lip

7. RisoriousOrigin: Fascia over parotid salivary gland

Insertion: Superior striata of orbicularis oris

Action: Draws angle of mouth laterally

b) Deep:

1. Levator anguli oris

Origin: From maxilla just below the intra orbital

foramenInsertion: Into the orbicularis oris

Action: Elevates the upper lip

2. Incisivus labi superioris

Origin: Lateral part of incisive fossa

Insertion: Into the skin of upper lip

Action: Changes the shape and form of lips

10


11/81

3. Mentalis

Origin: Mental protuberance

Insertion: Into the lower lip

Action: Elevates and protrudes the lower lip

4. Buccinator:

Origin: Alveolar process of maxilla mandible

Insertion: Into the orbicularis oris

Action: Compresses cheek

Nerve supply: All the above muscles are supplied by facial

nerve

11


12/81

PHYSIOLOGY

Nervous system controls all the activities of the body. Neuron is defined as the structural and functional unit

of the nervous system.

Depending upon the length of the axon neuron are

divide into

1. Golgi type-1

2. Golgi type-2 neuron

In the central and peripheral nervous system the

neuron has almost alike structure, with nerve cell body

dendrite and axon.

Nerve cell body has nucleus, nissal granules and axon

hillock.

Dendrites are the branched processes of the neuron,they are afferents.

The axon is the longer process of the nerve cell arising

from axon hillock, which acts as efferent.

The nerve is covered by epineurium, fasciculus is

covered by perineurium and each fiber is covered by

endoneurium.

12

Properties of nerve fibers:


13/81

The properties of nerve fiber are

1.Exitability

2.Conductivity3.Refractory period

4.Summation

5.Adaptability

6.Infatigability

7. All or none law

1. Exitability:It is defined as the physiochemical change that

occur in a tissue when a stimulus is applied.

The stimulus is defined as an external agent, which

produces excitability in the tissues.

Action potential:

When the nerve is stimulated, a series of changesoccur in the membrane potential, which is together called

as action potentials.

If depolarization at a spot on the cell reaches the

threshold voltage, the reduced voltage now opens up

hundreds of voltage gated channels in that portion of the

plasma membrane. During the millisecond that the channels

remain open, some 7000Na+ rushes into the cell. Thesudden complete depolarization of the membrane opens up

13


14/81

more of the voltage-gated channels in adjacent

portions of the membrane. In this way, a wave of

depolarization sweeps along the cell. This is the action

potential. (In neurons, the action potential is also called thenerve impulse)

2. Conductivity:

The action potential is transmitted through the

nerve fiber as nerve impulse.

The action potential is transmitted through the nerve

fiber in only one direction.

3. Refractory period:

It is the period at which the nerve does not give

any response to a stimulus.

4. Summation:

When one stimulus is applied, it does not produce

any response in the nerve fiber.However, if two or more

subliminal stimuli are applied within a short interval ofabout 0.5msec, the response is produced .It is because the

subliminal stimuli are summed up together. This

phenomenon is known as Summation.

5. Adaptation:

While stimulating a nerve fiber continuosly, the

excitability is maximum in the beginning. Later theresponse decreases slowly and finally the nerve finally the

nerve fiber doesnt show any response .This phenomenon is

known as adaptation or accommodation.

14


15/81

6. Infatigability:

A nerve fiber cannot be fatigued, even if it is

stimulated continuously for a long time. The reason is the

nerve can conduct only one action potential at a time. Atthat time, it is completely refractory and doesnt conduct

another action potential.

7. All or none law:

When a nerve is stimulated by a stimulus with

sub threshold strength, action potential doesnt develop. If

the strength of stimulus is above the sub threshold level,whatever may be the strength of stimulus, the amplitude of

action potential remains same .This is known as all or none

law.

Synapse:

The junction between the two neurons is called as

synapse.

It may be classified anatomically or functionally

Anatomical classification:

Depending upon the ending of the axon, the synapse is

classified into 3 types.

1. Axosomatic synapse

2. Axodentritic synapse

3. Axoaxonic synapse

15


16/81

Functional classification:

On the basis of transmission of impulses, the synapse

is classified into1. Electrical synapse

2. Chemical synapse

Electrical synapse:

In this, there is continuity between the pre&post

synaptic neurons.>The continuity is provided by gap junction between the

two neurons.

>There is minimal synaptic delay because of the direct flow

of current.

Chemical synapse:

In this there is no continuity between the pre & post

synaptic neuron because of presence of a space called

synaptic cleft between two neurons.Properties of synapse:

1. One way conduction:

The impulses are transmitted only in one direction in

synapse

2. Synaptic delay:

During the transmission of impulses via the synapse,

there is a little delay in the transmission.3. Fatigue:

During continuous muscular activity the synapse

forms seat of fatigue.

16


17/81

4. Summation:

When many numbers of presynaptic excitatory

terminals are stimulated simultaneously or rapidly, there

are summation or fusion effects in post synaptic neurons.Summation is partial or temporal.

5. Electrical property:

These are the excitatory post-synaptic and inhibitory

post-synaptic potential.

Neurotransmitters:

The chemical mediator substances responsible for thetransmission of impulses through a synapse.They are

Acetyl choline

Amines like

nor adrenaline

Dopamine

Seratonine

HistamineAmino acids like

Gamma amino buteric acid(GABA)

Glycin

Glutamate

Aspertate

Substance-P

Encephaline

17


18/81

Types of neurotransmitters:

1. Excitatory

2. Inhibitory

Reflex arch:

The anatomical nervous pathway for a reflex action is

called reflex arch.

Mechanism:

From the receptor the impulses are transmittedthrough the afferent nerve & they are transmitted through

the afferent nerve & they are transmitted to the center i.e to

the cerebellar/ cortical reflexes & from there the

descending impulses are transmitted to the efferent nerve to

the efferent organ that is to the muscle.

18


19/81

ETIOLOGY

Bells palsy is caused by an inflammation of the facialnerve where it exists the skull within its bony canal

(fallopian canal), blocking the transmission of neural

signals because the width of the canal is smaller at its

proximalpart, the nerve is thicker at that point because

it contains more nerve fibers.

Viral and bacterial infection as well as auto immunedisorders appears to be emerging as the most frequent

common threat in etiology of bells palsy.

Herpes simplex-1:

The triggers for reactivation of the virus prior to the

set of bells palsy have not been proven

conclusively

Impaired immunity

Herpes zoster.

Temporary causes:

Stress

Lack of sleep

Minor illness

Physical trauma.

Upper respiratory infection.

19


20/81

Long term causes:

Auto immune disorders.

Chronic diseases etc., are strongly targeted as the

most likely triggers Viruses including cytomegalovirus, Epstein-Barr

rubella

Mumps

Ramsey hunt syndrome:

HIV/ AIDS increase the chance of developing of

Bells palsy. Exposure to chill or cold weather causes

compression of facial nerve.

Fracture of mastoid

Craniotomy (surgery induced).

Infection of internal ear (otitis media).

Road traffic accidents.

Trauma due to blunt force. Temporal bone fracture.

Brain stem injuries.

Acoustic neuroma.

Cysts and tumors.

Diabetes.

Thyroid conditions.

Lupus, stogerms syndrome. Congenital defects.

Tooth extracts.

20


21/81

PATHOLOGY

Lower motor neurons:

Bells palsy is a LMN lesion

LMN are the anterior gray horn cells in the spinal

cord and the motor neuron of the cranial nerve

nuclei in the brain stem which innervate the muscles

directly.

Thus the lower motor neurons constitute the finalcommon pathway of motor system.

Lower motor neuron is under the influence of upper

motor neurons.

Effects of LMN lesion:

Clinical observations:

Muscle tone-hypotonic

Paralysis-flaccid type.

Wasting of muscle.

Superficial reflexes are lost.

Plantar reflexes are absent.

Deep reflexes are lost.

Clonus is absent.

Clinical confirmation:

Electrical activity is absent

Individual muscles are affected.

Fascicular twitch in EMG is present.

21


22/81

Types of LMN lesion:

Peripheral nerve fiber lesion damage to a LMN

involve either the anterior horn cells or the fibers of thenerve roots or peripheral nerves, lesions involving the

nerve fibers can be classified into

1. Neuropraxia.

2. Axontemesis.

3. Neurotemesis.

Neuopraxia (1ST

degree injury):It is a condition in which bruising or pressure

renders the nerve in capable of conducting impulses. Past

the site of the lesion. Degeneration does not occur.

Axonotemsis (2nd degree injury):

It is liable to occur if the lesion is more severe.

Degeneration of the axon takes place. The sheath of the

nerve remains intact.

Neurotemsis (3rd degree injury):

It is sever, the nerve sheath and fibers are not in

intact, the fibers degenerate below the site of the lesion, the

condition is more serious as suture of the nerve is necessary

before satisfactory nerve regeneration takes place.

All these types of lesion may be partial or

complete and there may be a combination of two of them.

22


23/81

The facial nerve becomes swollen and

hyperaemic with in the facial canal, in which there is

limited space. The nerve rapidly becomes compressed and

conductivity is lost.

Regeneration:

The degenerated nerve fiber may be regenerated.

The regeneration of the injured nerve can occur only under

favorable conditions regeneration starts early as 4th day

after injury, but becomes more effective only after 30 days

and is completed about 80 days.The regeneration of the nerve fiber occurs if the

following criteria are fulfilled.

1. The gap between the cut end of the nerve should not

exceed 3mm.

2. The neurilemma should be present. As neurilemma

is absent in central nervous system, the regeneration

of nerve does not occur in CNS.

3. The nucleus must be intact. If the extruded fromnerve cell body, the nerve is atrophied and, the

generation does not occur.

4. The two ends should remain in the same line.

Regeneration does not occur if any one end is

moved away.

Stages of Regeneration:1) First the cells of Schwann from the proximal and

distal cut ends of the nerve grow out in all

directions in the form of

23


24/81

Pseudopodia like fibrils. The number of the fibrils is

up to 100. The fibril from one end established contact

with the fibrils of the other end and fill up the gap

between two cut ends of the nerve. The activity of theproliferation schwann cells is greater in distal end than

in proximal end. The filling up of the gap leads to the

development of continuity of neurilemmma tube.

2) Later, the axis cylinder is fully established inside

the neurilemmal tube. These processes are complete in

about 3 months after injury.

3) The myelin sheath is formed by the cells of

Schwann slowly. The myelination is completed in one

year.

4) The diameter of the nerve fiber gradually increases.

However the degenerated nerve fiber obtains only

80% of original diameter.

5) In the nerve cell body, first the nissal granules

appear followed by golgi apparatus.

6) The cell looses the exceeds fluid the nucleus

occupies the central portion.

7) Though the anatomical regeneration occurs in the

nerve, the functional recovery occurs after a long

period.

24


25/81

CLINICAL FEATURES

The VIIth facial cranial nerve has both motor and

sensory functions. Its motor functions include shutting the eye, lifting

the eyebrow, and supplying the muscles that move

the mouth and lips.

Its sensory functions include tasting on the front of

the tongue and dampening the level of the sound we

hear.

So the symptoms of Bells palsy include anyabnormalities involving these various muscles.

Many people describe feeling a pain behind their

ear or near the jaw a few days before the other

symptoms develop. Symptoms begin suddenly and

hit their peak usually with in 48 hours.

Seventy Five percent of cases are preceded by

upper respiratory infection or a viral infection.

Clinical Features:

The most common symptom of Bells palsy is

weakness on one entire side of the face. Sudden

one sided facial paralysis or weakness of the

facial muscles.

A person may not be able to close one eye,

inability to blink, or they may have difficulty

shutting their eye completely. Diminished

blinking and the absence of tearing together can

25


26/81

reduce or eliminate the flow of tears across the

eyeball, resulting in drying, erosion, and ulcer

formation on the cornea and possible loss of the

eye. The forehead doesnt wrinkle when a person tries

to lift their eyebrow.

The lower part of the face may drop down.

Patients arent able to lift their mouths to smile

or fill their cheeks with air.

They may drool from the mouth.

Some people may feel a tingling, twitching ornumbness in the face. Face feels stiff or pulled to

one side, change in facial appearance, difficulty

with facial expression, grimacing etc, difficulty

with fine facial movements, asymmetrical smile.

Dry eyes or tearing (crocodile tears).

Pain in the back of the head, ear, behind the ear,

or the affected side of the face. Hypersensitivity to sound (hyperacusis) or

hearing deficit.

Dry mouth and impairment of taste.

Difficulty with eating and drinking.

Speech is affected.

Nose feels stuffed or blocked, or runs.

Pain in or near the ear. Blisters in the ear. Fatigue and dizziness (vertigo).

Tooth decay and gum disease due to reduced

saliva and impairment of chewing.

26


27/81

INVESTIGATIONS

STRENGTH DURATION CURVE:

Introduction:

The plotting of strength duration curve is the most

satisfactory method at present available for the

routine testing of electrical reaction in nerve lesion.

Apparatus:

Electrical stimulator (muscle)Rectangular impulses of different duration of 0.01,

0.03 0.1, 0.3, 1, 3, 10, 30 & 100 milli seconds are

required.

Technique:

Before applying the current, the skin resistance is

reduced. An inactive electrode is placed on the nape

of the neck at spinal cord level. Active electrode isplaced on the motor point of the muscle current is

applied, using the largest stimulus first and increased

until a minimal current is obtained. A minimal

contraction is used, as this makes it easy to detect

any change in strength. Next the duration is

decreased and gradually intensity is increased and

when minimal contraction is noted the graph isplotted against duration on x-axis and intensity on y-

axis.

27


28/81

Kink:

An easy sign of re-innervation of the nerve supply to

a muscle may change in the shape of the strength

duration curve and as re- innervating progresses thecurve moves down and to the left. Progressive

denervation is indicated by the appearance of a kink.

Kink is the point where the innervated and

denervated muscles section meets. Kink in the graph

shows partial innervation.

Advantages:It is the simple and reliable method and indicates the

proportion of denervation.

Disadvantages:

It does not indicate the site of the lesion.

HEARING TEST:

Determines the cause of damage to the nerve hasinvolved the hearing nerve, inner ear, or delicate

hearing mechanism.

BALANCE TEST:

Evaluates balance, nerve involvement.

TEAR TEST:Measures the eyes ability to produce tears.

28


29/81

X-RAY:

Shows the fractures.

IMAGING:CT (computerized tomography) or MRI (magnetic

resonance imaging) determines if there is infection,

tumor, bone fracture or other abnormalities in the

area of the facial nerve.

NERVE CONDUCTION TEST:

Stimulates the facial nerve to assess how badly thenerve is damaged. This test may have to be repeated

at frequent intervals to see if the disease is

progressing.

LABORATORY STUDIES (BLOOD STUDIES):

It may be necessary to determine the underlying

cause like auto immune problems, Lyme disease or

other viral infections which can lead to Bells palsy.

29


30/81

DIFFERENTIAL DIAGNOSIS

Ramsey hunt syndrome:

1. It is similar to Bells palsy unlike Bells palsy, thevirus that cause Ramsey hunt syndrome has been

conclusively identified. It is Varicella zoster virus.

2. The first symptom is usually severe pain. There may

be fever, headache and localized tenderness.

3. In addition to classic symptom of bells palsy Ramseyhunt syndrome is associated with some additional

symptoms that help to differentiate.

Pain:

Bells palsy patients may complain of pain often in or

behind the ear which can be acute. However, it will tend to

face with in a week or two. The pain associated with

Ramsey hunt syndrome is often more severe, and morelikely to be felt inside the ear. It may start before muscle

weakness is apparent, and may last for weeks or months,

some times longer.

Vertigo:

Dizziness is occasionally reported by bells palsy

patient, but often associated with Ramsey hunt syndrome. Itcan be more severe and long lasting.

30


31/81

Hearing loss:

Ramsey hunt syndrome can also affect the auditory

nerve, resulting in hearing deficit. This should not occur

with bells palsy is an important to diagnose for physician.

Blisters:

The primary symptom that makes a diagnosis of

Ramsey hunt syndrome likely is the appearance of blisters

in ear. The blisters can appear prior to, concurrent to, or

after the onset of facial paralysis. They can be expected last

2-5 weeks, and can be quite painful. The pain can continueafter the blisters have disappeared. Swollen and tender

lymphnodes near the affected area.

Hemifacial spasm:

Hemifacial (vs) Bells palsy

1. Synchronous contraction of all muscles innervated by

the facial nerve

2. Facial nerve in the hemi facial spasm is irritated at thefacial nerve root or facial nerve nucleus.

3. The etiology remains unknown.

4. Onset usually occurs in middle to old age and women

are preferentially affected.

Bells palsy: Synkinesis

1. Involuntary movement of muscles with volitionalmovements.

2. The facial nerve in the Bells palsy is by the

compression or partial cut.

31


32/81

3. Complete cut of the facial nerve at the stylomastoid

foramen.

4. The etiology is by the trauma infections of ear, toothextracts, inflammations, exposure to the cold weather.

5. This is common condition, affecting all ages and both

sexes.

Facial palsy (vs) Bells palsy:

1. The patient ability to wrinkle the forehead is impaired

in a lower motor neuron (bells palsy) but, it is notimpaired in upper motor neuron lesion(facial palsy)

2. In the presence of LMN lesion, the eye can be rolling

up as an ineffectual to shut the eyelids is made.

3. In an UML lesion very slight weakness of eye closure

is usually detectable as an inability to bury the

eyelashes completely on the affected side.

4. In a LMN lesion profound asymmetry is obvious. In

an UMN lesion slow and incomplete movement of themouth, on the opposite the casual lesion may be noted.

32


33/81

DIAGNOSIS

BELLS PHENOMENON:

Lateral and upward movement of eye ball and

deviation of mouth to opposite side.

32


34/81

TREATMENT

Medical treatment:

Medication that may help to the compression. They should be started as quickly as possible.

There is no proven medical treatment, through a

course of steroids such as PREDNISOLONE 40-60

mg daily for a week may speed recovery.

Medications are started from the 7days on set of Bells

palsy.

Prednisolone may be prescribed later if it appears theinflammation has not subsided.

Steroids are safe and probably effective in

improving facial functional outcomes in patients with

bells palsy results show significantly better out comes

with steroids, however, they do not final any

difference in the time frame for recovery.

Antivirals: Acyclovir combined with prednisone is more effective

in improving facial functional out comes in patients

with Bells palsy.

The most important part of treatment is to keep the

eyes healthy and moist. One of the purposes of

blinking and closing the eyes is to keep the eyes wet.

If a person cant close their eyes, because the muscles

that control the eyelids are paralyzed, it is important tokeep the eyes moist and prevent itching. Eye drops are

prescribed for the day and an eye ointment for the

33


35/81

night to prevent drying of the surface of the eye

cornea. Diminished blink and the absence of tearing

together can reduce or eliminate the flow of tears

across the eyeball, resulting in the drying, erosion, andulcer formation on the cornea and possible loss of the

eye. Closing the eye with finger is an effective way of

keeping the eye moist. Use the back of the finger to

ensure that the eye is not injured with the finger tip.

Protective glasses or clear eye patches are often used

to keep the eye moist, and to keep foreign materials

from entering the eye. Rest is important.

Wear glasses with tented lenses or sunglasses.

Facial electrical muscle stimulation

Facial exercises

Rehabilitation

Surgical management:Decompression of the facial nerve can be

accomplished by micro surgical procedure.

For Bells palsy it remains controversial, even when

nerve degeneration is severe.

Complications:

1) Hearing loss

2) Facial nerve damage

34


36/81

Prognosis:

The prognosis for Bells palsy is generally very good. With

or without treatment, most patients begin to get

significantly better with in 2 weeks, and about 80 percentrecover completely with 3 months. For some, however, the

symptoms may last longer. In a few cases, the symptoms

may nerve completely disappear. Only in 10 patients nerve

experience a complete disappearance of symptoms. The

extent of nerve damage determines the extent of recovery.

There is no specific treatment for Bells palsy.

35


37/81

ASSESSMENT

Subjective assessment:

Name :Age :

Occupation :

Chief complaints :

History:

Present history :

Past history :

Personal history : AlcoholicSmoke

Medical history : Diabetes

Hypertension

Socio-economic history : Poor

Middle class

High class

Objective assessment:

On observation: Facial expression

Bells phenomenon

Position of eye ball

Mouth deviation

Skin appearanceSwelling

On palpation : Tenderness

Warmth

36


38/81

On Examination:

1) Motor examination

a) Manual muscle testing: Orbicularis oris

MentalisOrbicularis occuli

Muscles of mastication

Muscles of tongue etc.

2) Sensory examination: Gustatory sense

3) Reflexes: Strength duration curve (type of lesion)

Nerve conduction velocity test (site of

lesion)X-ray (fractures),

C.T.scan, M R I (tumours)

Differential diagnosis : Ramsey hunt syndrome,

Pain,

Vertigo

Hearing loss,

Hemifacial spasm

Provisional diagnosis:Problem list :

Means :

Physiotherapy management:

Home programme :

37


39/81

PHYSIOTHERAPY MANAGEMENT

Physiotherapy plays an important role in treating the

patient with Bells palsy by means of electrical stimulation,facial massage, facial exercises and home advices.

Electrical stimulation:

Electrical stimulation is given to the patient with

Bells palsy in order to maintain the muscle properties of

facial muscles.

It is done by using galvanic and faradic currents.Galvanic current:

Facial muscles are stimulated by galvanic current

which is a unidirectional current of unvarying intensity and

has less refractory period with 300-600 milli seconds

duration, rectangular impulse, 10Hz of frequency, which

will give brisk contraction.

Uses:

With the galvanic current occurs, so that the wasteproducts are removed and increased blood supply,

along with nutrients.

With the cathodial galvanism, counter irritation takes

place & pain is relieved.

In Bells palsy cathodal galvanism is used with large

anode and small cathode. Here active electrode is

cathode (pen electrode) inactive electrode is anode(plate electrode).

38


40/81

Active pen electrode is small 2milli ampere per square

inch.

Facial muscles are situated superficially and they are

very small. So the resistance of the underlying tissue ismuch less than that of the skin. Hence , the current

spreads considerably once it has passed through the

skin, so therefore the effects are much greater in the

superficial than in the deep tissues, because of this

galvanic current is used for stimulation of the facial

muscles and it also has small refractory period.

Impulse- Rectangular Duration- 100 milli seconds

Intensity- Vary according to duration and regeneration

of the nerve and individual tolerance.

Placement of electrodes:

Inactive plate electrode is placed over the nape of

the neck.

Active pen electrode is used for stimulating themuscles by keeping the pen electrode over the

motor points of facial muscles.

Faradic current:

Nerve branches are stimulated by the faradic

current which is having frequency of 50

cycles/seconds and 1milli second duration.

With surged faradism, gives contraction of thecorresponding muscles similar to a voluntary

contraction.

39


41/81

Surged faradism is mainly given at three areas

1. Lower branch is stimulated at the angle of jaw.

2. Middle branch is stimulated in front of the ear.

3. Upper branch is stimulated at the corner angle ofthe eye.

Duration-100 milli seconds

Intensity-Vary according to duration and regeneration

of the nerve and individual tolerance.

Placement of electrodes:

Inactive plate electrode is placed over the nape of

the neck Active pen electrode is used for stimulating the

nerve trunks by keeping the pen electrode over

them.

MASSAGE:

Massage should be performed to the patient in order to

improve circulation, venous & lymphatic flow.Stroking:

Performed in an upward, outward direction.

Effect:

Stroking stimulates the cutaneous touch receptors,

stimulates the peripheral nerves.

Effleurage:

It is the movement of the palmar surface of the hand

over the external surface of the body with constantmoderate pressure in the direction of venous and

lymphatic flow.

40


42/81

Essential features:

Contact and continuity should be maintained

throughout the technique.

Effects and uses: It facilitates the circulation in the capillaries.

Increase arterial circulation, which increases the

nutrition of the part, tone of the muscle is improved.

Finger pad kneading:

Interphalangeal joint of thumb is flexed and

constant pressure is applied. Thumb tip kneading improves circulation of the

muscles and its nutrition is increased over the facial

muscles, given in cases Bells palsy, myofacial

pain, facial palsy.

It is given at the eye brows, over the eyelids, angles

of the nose & around the mouth.

Hacking:

Reversal of hacking is given over the muscular

areas.

Alternate supination and pronation of the forearm

combined with ulnar and radial deviation of the

wrist and palmar surface of the medial border of

medial three fingers will come and contact with the

skin, these movements will produce hacking.

41

Hacking is given to stimulate and warm up a part

generally.


43/81

These techniques applied for 5minutes or so daily

help to maintain lymphatic and blood flow to

prevent contractures.

VIBRATIONS:

Constant touch of the therapist finger with the patient

skin and application of rapid intermittent pressure with out

changing position of hand.

Technique:

Co-contraction of the upper extremity, there isosciallatory movement of hand in up ward and down

ward direction and transmits the mechanical energy.

It is perfomed on the stylomastoid foramen.

Exercises:

Exercises are taught to the patient to increase the

muscle power.1. Look surprised then frown.

2. Squeeze eyes closed then open wide.

3. Smile, grin say O

4. Say A E I O U

5. Hold straw in mouth then suck and blow

whistle.

6. Puffing of air in mouth

7. Chewing bubble gum.

42

Adhesive plaster:


44/81

Pull the deviated side of the mouth to affected side.

It is applied on the affected side of the face in form

of inverted Y shape.

Application:

One strap applied from the lateral angle of the eye

towards the ear, another is applied from the lateral angle of

the mouth towards the ear maintaining a fold on cheek.

Adhesive plaster is also applied parallelly pulling the

deviated side towards the affected side.

Resisted Exercises:

Manual resistence: The thumb or index finger is placed

lightly over the opened eyelid above the lashes, and

resistance is given in a downward direction (to close the

eye.)

Instruction to patients:

Open your eyes wide, hold it, dont let me close them.

Orbicularis Occuli:

Manual resistance:

Place the thumb and index finger below and above

(respectively) each closed eye using a light touch. The

examiner attempts to open the eyelids by spreading the

thumb and index finger apart.

43

Instruction to patient:


45/81

Close your eyes as tightly as you can hold them closed.

Dont let them open them or close your eye against my

finger.

Corrugator supercilii:

Manual resistance: The examiner uses the thumb (or index

fingers) of each hand placed gently at the nasal end of each

eyebrow and attempts to move the eyebrows apart

(somoothers away the frown)

Instruction to the patient:

Frown. Dont let me erase it,

Occipitofrontalis:

Manual resistance:

Examiner places the pad of a thumb above each eyebrow

and applies resistance in a downward direction (smoothing

the forehead).


Raise your eyebrow as high as your can. Dont let me pullthem down.

Procerus:

Manual resistence:

The pads of the thumbs are placed beside the bridge of the

nose, and resistence is given laterally (smoothing the

creases)

44

Obicularis oris:


46/81

Manual resistence:

A tongue blade rather than a finger is uses to provide

resistence in deference to hygiene. The blade is placed

diagonally across both upper and lower lips, and resistenceis applied in ward toward the oral cavity.


Purse your lips. Hold push against the tongue blade.

Buccinator:

Manual resistence:A tongue blade is uses for resistence. The blade is placed in

side the mouth, its flat sidelying against the cheek.

Resistence is given by levering the blade inward against the

cheek (at the angle of the mouth), which will cause the flat

blade to push the test cheek outward.

Alternatively, the gloved index fingers of the examiner

may be used to offer resistance. In this case, the gloved

index fingers are placed in mouth (the left finger to theinside of the patients left cheek and vice versa). The

fingers are used simultaneously to try to push the cheeks

outward. Use caution in this form of the test for patients

with cognitive impairment (test they bite) or with those

who have a bite reflex.

Instruction to patient:Suck in your cheeks. Hold doesnt let me push them out.

45

Levator labii superior alaeque nasi:


47/81

These two muscles elevate the upper lip. The labii

superioris also protracts the upper lip, and the alaeque nasi

dilates the nostrils.

Home programme:

Using mufflers

Wearing goggles

Avoid doing head bath frequently

Pronouncing the letter A, E, I, O, U.

Mirror exercises

Clenching the teeth Compressing the nose,smiling

Wearing adhesive plasters

Look surprised then frown

Hold straw in mouth,suck and blow

Blowing of air in between the cheek

Chewing a chewing gum

These exercises are performed in lying then insitting position. The patient may assist at first then

progress to resisting.A mirror is useful to enable the

patient observe the muscle, it is not necessary for

the patient to be seen by the physiotherapist very

often, but monitoring visits should be arranged.

46

REHABILITATION


48/81

Face is the image of the soul

Facial palsy is a disability of communication as

human beings, our primary form of non-verbalcommunication relies upon minute changes in facial

expression that reveal our innermost feelings.

Just as an aphasic person cannot communicate

verbally after stroke, the patient with facial

paralysis cannot convey the normal social signals of

interpersonal communication.

Those who work with facial paralysis patients areactually aware of rehabilitation both the

physiological and psychological aspects of this

disability.

Restoring function and expression to the highest

level possible results in improved health, self

esteem, self acceptance by others, and quality of

life. Neuromuscular retraining is gaining recognition as

an element for optional recovery form facial nerve

paralysis retraining techniques have developed for

treating sequelae that range from flaccidity to mass

action and synkinesis, improving facial motor

control and enhancing patient satisfaction and

outcomes.

47


49/81


50/81

CASE I


Name : L.Aruna KumariAge : 48 Years,

Gender : Female,

Occupation : House Wife,

Chief complaints : a) Mouth is deviated to left side,

: b) Unable to chew food properly,

: c) Unable to close right eye,

: d) Food particles stay in betweenthe teeth and cheek.

History:

Present history : Her mouth is deviated to left side and

she is also unable to chew food

properly. She cannot close her right

eye. Food particle stay in between teeth

and cheek on right side.

Past history : When she exposed to cold air her

mouth is deviated to left side. At that

time she had pain in the ear. She was

unable to close her right eye and unable

to speak. She was also under

medications.

Personal history : No relevant factors

49


51/81

Medical history : She is not diabetic, but known.

Hypertension

Socio-economic history : Middle class



Frowning is difficult on right side,

bells phenomenon is positive on

right side. Mouth deviation ispresent towards left. Position of

eye ball is lateral on right side,

skin is pale, swelling on right side.

On palpation : Tenderness is present at ear,

warmth is absent.

On Examination:


a) Manual muscle testing: Mentalis

Orbicularis occuli,

Orbicularis oris,

Muscles of mastication, etc.

Are unable to do the action.

2) Sensory examination: Gustatory sense is metallic.

50


52/81

3) Reflexes: Naso lacrimal reflex is absent.

Palmomental reflex is absent.

Corneal reflex is absent.

Investigation : S D curve shows denervation.Blood reports are normal.

X ray shows no fracture

Provisional diagnosis : Right side Bells palsy.

Problem list : 1) Unable to close right eye

properly.2) Speech is difficult

3) Eating, Chewing is difficult.

4) Mouth deviated to left side.

Means & Treatment :

1) Counseling, Explaining the course, features and

prognosis of the disease.



GALVONIC CURRENT: Duration 100 milliseconds,

Intensity Vary according to

duration and regeneration of thenerve and individual tolerance.

51


53/81

FARADIC CURRENT: Duration 0.1 to 0.3 milliseconds,


duration and regeneration of the

nerve and individual tolerance.

2) Facial massage.

3) Adhesive plaster.

4) Exercises: Whistling.

Hold straw in mouth, then suck and blow air

or water.

Pronounce vowels A E I O UHome Programme:

Use muffler and cotton in the ear

Wearing goggles

Avoid head bath for 15 days

Pronouncing the letter A E I O U

Mirror exercises like showing the teeth

Compressing the nose, smiling Look surprised then frown

Hold straw in mouth, suck and blow

Blowing of air in between the cheek.

Chewing bubble gum

These exercises are performed in lying at first then

sitting. The therapist may assist at first then progress

to resisting. A mirror is useful to enable the patientobserve the muscle. It is not necessary for the patient

to be seen by the physiotherapist very often, but

monitoring visits should be arranged.

52


54/81

CASE II


Name : G.Rama Devi.Age : 31Years,

Gender : Female,

Occupation : Clerk,

Chief complaints : a) Mouth is deviated to right side,


: c) Unable to close Left eye,


History:

Present history : Her mouth is deviated to right side

and she is also unable to chew food

properly. She cannot close her left eye.

Food particle stay in between teeth and

cheek on left side. Pain on left side ofthe face.

Past history : One Year back during pregnancy

period she had an attack that leads to

mouth deviation and again she had an

2nd attack of same problem, she had

under gone medications and alsophysiotherapy, she unable to speak and

close her left eye.

53


55/81


Medical history : She is not diabetic, and no history of

hypertension.




Frowning is difficult on left side,bells phenomenon is positive on

left side. Mouth deviation is

present towards right. Position of

eye ball is lateral on left side, skin

is pale, swelling on left side.


warmth is absent.

On Examination:



Orbicularis occuli,

Orbicularis oris,Muscles of mastication, etc.


54


56/81


57/81





2) Facial massage.




or water.



Wearing goggles







Chewing bubble gum






56


58/81

CASE III


Name : B.Nimisha,Age : 17 Years,

Gender : Female,

Occupation : Student,

Chief complaints : a) Mouth is deviated to right side,


: c) Unable to close left eye,


History:

Present history : Her mouth is deviated to right side

and she is also unable to chew food

properly. She cannot close her left eye.

Food particle stay in between teeth and

cheek on left side.

Past history : When she exposed to cold air her

mouth is deviated to right side. At that

time she had pain in the ear. She was

unable to close her left eye and unable

to speak. She also had a history of

previous history of attack of earinfection. She was also under

medications.

57


59/81


Medical history : She is not diabetic, and no history of

Hypertension




Frowning is difficult on left side,bells phenomenon is positive on

left side. Mouth deviation is

present towards right. Position of

eye ball is lateral on left side, skin

is pale, swelling on left side.


warmth is absent.

On Examination:



Orbicularis occuli,

Orbicularis oris,Muscles of mastication, etc.


58


60/81

2) Sensory examination: Gustatory sense is metallic.

3) Reflexes: Naso lacrimal reflex is absent.

Palmomental reflex is absent.Corneal reflex is absent.

Investigation : S D curve shows denervation.

Blood reports are normal.

X ray shows no fracture

Provisional diagnosis : Left side Bells palsy.

Problem list : 1) Unable to close left eye

properly.

2) Speech is difficult

3) Eating, Chewing is difficult.

4) Mouth deviated to right side.

Means & Treatment :

1) Counseling, Explaining the course, features andprognosis of the disease.



GALVONIC CURRENT: Duration 100 milliseconds,Intensity Vary according to



59


61/81





2) Facial massage.




or water.



Wearing goggles







Chewing bubble gum






60


62/81

BIBILIOGRAPHY

1) Human Anatomy : B. D. Chaurasias Human

Anatomy (Volume-3) FourthEdition.

2) Human Anatomy : KENT M.VA DE GRAAFF

3) Clinical Anatomy : Richard S.Snell-5th Edition.

4) Mc.Minns Functional andClinical Anatomy : 1) Robert M.H.Mc.MINN

: 2) Bari M.Logan

5) Essentials of medical

Physiology : K.Sembulingam-4th Edition

6) Brain and Bannisters

Clinical Neurology : Sir Roger Bannister

7) Tidys physiotherapy : Thompson, Skinner piercy,

14th edition,

8) Pathophysiology of

the motor systems : Christopher M.Fedrics,

Lisa K. Saladin

9) Daniels & worthinghsams

Muscle testing : Sir Stanley DAVIDSON

20TH Edition.


63/81

10) Neurology and neuro

Surgery : Kenneth W.Lindsay, lan

bone 5th Edition.

11) Neurological differential

Diagnosis : John patten,

Mark Mumenthalar

12) Claytons Electrotherapy : Angela FORSTER

Nigel palastanga 9th Edition

13) Text book of pathology : Harsh Mohan 5th Edition


64/81

INTRODUCTION


65/81


66/81

MYOLOGY


67/81

PHYSIOLOGY


68/81


69/81


70/81


71/81

INVESTIGATIONS


72/81

DIFFERENTIAL

DIAGNOSI

S


73/81

DIAGNOSIS


74/81

TREATMENT


75/81

PHYSIOTHERAPY

ASSESSMENT


76/81


77/81

REHABILITATION


78/81

CASE STUDY


79/81


80/81

1.INTRODUCTION

2.ANATOMY.

3.PHYSIOLOGY.

4.ETIOLOGY.

5.PATHOLOGY.

6.CLINICAL FEATURES

7.INVESTIGATIONS.

8.DIFFERENTIAL DIAGNOSIS.

9.DIAGNOSIS.

10.TREATMENT.

11.PT ASSESSMENT.

12.PHYSIOTHERAPY MANAGEMENT.

13.RAHABILITION.

14.CASE STUDY -1

15.CASE STUDY-2

16.CASE STUDY-3

17.BIBLIOGRATHY.


81/81

Sravani Bells Project Report

Documents

Transcript of Sravani Bells Project Report