Bell’s Palsy

Overview of Bell’s Palsy

The most common form of facial paralysis is Bell’s palsy. The annual incidence of this idiopathic disorder is ~25 per 100,000 annually, or about 1 in 60 persons in a lifetime. Risk factors include pregnancy and diabetes mellitus. a lower motor neuron lesion of the 7th (facial) nerve, affecting all ages and both sexes. [1]

Causes

(a) known clinical conditions – Diabetes, severe hypertension, last trimester of pregnancy, dental anesthesia.

(b) Causes – Associated

(i) Firstly, Exposure to cold; oedema and subsequent compression of nerve trunk within the rigid fallopian canal causes circulatory disturbance.

(ii) Secondly, Other important causes of acute facial palsy include suppurativa otitis media, herpes zoster, head injury, Guillain-Barre syndrome, sarcoidosis and multiple sclerosis [2]

Types

Bell’s palsy is not classified into distinct types. Instead, the book describes it as a "monophasic, self-limited facial nerve palsy of unclear etiology." While variations in severity and recovery time exist, these are not considered distinct types of the condition. (1)

Risk factors of Bell’s palsy

• Family history of the disease
• Diabetes
• Autoimmune disorders
• Weakened immune system
• Infections
• Chemotherapy
• Pregnancy
• Certain medications
• Smoking
• Hypertension (6)

Pathogenesis of Bell’s Palsy

The pathogenesis of Bell’s palsy is described as follows:

"Bell’s palsy is thought to result from compression of the seventh cranial nerve at the geniculate ganglion. The first portion of the facial canal, the labyrinthine segment, is the narrowest; most cases of compression occur in the labyrinthine segment."

Which further elaborates:

"Due to the narrow opening of the facial canal, inflammation causes compression and ischemia of the nerve."

While the exact cause of the inflammation remains unclear, the book suggests that reactivation of herpes simplex virus type 1 (HSV-1) within the geniculate ganglion is the most likely etiology. Other possible causes include other viral infections (e.g., varicella zoster virus) and autoimmune mechanisms. (1)

Pathophysiology

Generally, In acute Bell’s palsy, there is inflammation of the facial nerve with mononuclear cells, consistent with an infectious or immune cause. Furthermore, Herpes simplex virus (HSV) type 1 DNA was frequently detected in endometrial fluid and posterior auricular muscle, suggesting that a reactivation of this virus in the geniculate ganglion may be responsible for most cases. Lastly, Reactivation of varicella-zoster virus is associated with Bell’s palsy in up to one-third of cases and may represent the second most frequent cause.

other viruses

In brief, A variety of other viruses have also been implicated less commonly. Additionally, an increased incidence of Bell’s palsy was also reported among recipients of inactivated intranasal influenza vaccine, and it was hypothesized that this could have resulted from the Escherichia coli enterotoxin used as adjuvant or reactivation of latent virus [3]

Clinical Features of Bell’s Palsy

• Acute onset of unilateral facial weakness: This typically develops over hours to days and may range from mild weakness to complete paralysis.
• Involvement of both upper and lower facial muscles: This distinguishes Bell’s palsy from central facial palsy (e.g., stroke), which typically spares the forehead muscles.
• Possible associated symptoms: These may include pain behind the ear, altered taste sensation (especially on the anterior two-thirds of the tongue), hyperacusis (increased sensitivity to sound), and decreased tearing.

The physical examination findings in Bell’s palsy include:

• Facial asymmetry: This is most noticeable when the patient attempts to smile, raise eyebrows, or close their eyes.
• Widening of the palpebral fissure: The eye on the affected side may remain partially open, even when the patient attempts to close it.
• Drooping of the corner of the mouth: This may cause drooling.
• Impaired ability to wrinkle the forehead: This distinguishes Bell’s palsy from central facial palsy.
• Loss of the nasolabial fold: This is a crease that runs from the side of the nose to the corner of the mouth.
• Decreased or absent corneal reflex: This reflex normally causes blinking in response to touching the cornea. (1)

Sign & Symptoms

• Sudden, following exposure to chill or without any apparent precipitating cause, maximum paralysis in 24 hours
• Moreover, Postauricular pain is common and may precede paralysis by 2 days
• Loss of sense of taste
• Hyperacusis also
• Watering of the eye
• Sweating less on affected side

Signs:

Forehead

• Forehead cannot be wrinkled; frowning lost (especially, frontalis).

Eye

• Eye cannot be closed (e.g. orbicularis oculi, sphincter of palpebral fissure). On attempting closure, eyeball turns upwards and outwards (in other words, Bell’s phenomena).

teeth

• On showing the teeth, the lips do not separate on affected side. Whistling not possible. Articulation of labial components difficult. Nasolabial fold flattened out. Angle of mouth on affected side droops with dribbling of saliva (in case of Orbicularis oris, sphincter of oral fissure).

Cheek

• Cheek puffs out with expiration because of buccinators paralysis. Food collects between teeth and paralysed cheek. Even Fluid runs out while drinking (specifically in buccinators).

tongue

• Base of tongue lowered (stylohyoid and posterior belly of digastric).

Vesicles within the external auditory meatus and ear drum in Ramsay Hunt syndrome. Pain may precede facial weakness. Deafness may result .[2]

Clinical examination of Bell’s Palsy

• Physical examination of patients with Bell’s palsy is usually remarkable for: unintended eye closure with an effort to smile, incomplete closure and the of the eye when patient attempts to close the eyes, inability to puff the cheek in affected side and impaired or absent taste in affected side, reduced hearing acuity. (7)

Diagnosis

There are many other causes of acute facial palsy that must consider in the differential diagnosis of Bell’s palsy. Lyme disease can cause unilateral or bilateral facial palsies; in endemic areas, 10% or more of cases of facial palsy are likely due to infection with Borrelia burgdorferi

Palsy is likely due to infection with Borrelia burgdorferi  The Ramsay Hunt syndrome, cause by reactivation of herpes zoster in the geniculate ganglion, consists of a severe facial palsy associated with a vesicular eruption in the external auditory canal and sometimes in the pharynx and other parts of the cranial integument; often the eighth cranial nerve is affected as well.

Facial palsy that is often bilateral occurs in sarcoidosis. . Leprosy frequently involves the facial nerve, and facial neuropathy may also occur in diabetes mellitus, connective tissue diseases including Jorgen’s syndrome, and amyloidosis.

The rare Melkersson-Rosenthal syndrome

• consists of recurrent facial paralysis; recurrent—and eventually permanent—facial (particularly labial) edema; and, less constantly, plication of the tongue. Its cause is unknown.

Acoustic neuromas

frequently involve the facial nerve by local compression.

Infarcts, demyelinating lesions of MS, and tumors are the common pontine lesions that interrupt the facial nerve fibers; other signs of brainstem involvement are usually present. Tumors that invade the temporal bone (carotid body, cholesteatoma, dermoid) may produce a facial palsy, but the onset is insidious and the course progressive

All these forms of nuclear or peripheral facial palsy must distinguish from the supranuclear type. In the latter, the frontalis and orbicularis oculi muscles of the forehead involve less than those of the lower part of the face, since the upper facial muscles innervate by corticobulbar pathways from both motor cortices, whereas the lower facial muscles innervate only by the opposite hemisphere. In supranuclear lesions, there may a dissociation of emotional and voluntary facial movements, and often some degree of paralysis of the arm and leg or an aphasia (in dominant hemisphere lesions) is present. [1]

Differential diagnosis of Bell’s Palsy

• Otitis media
• Ramsay Hunt syndrome
• Sarcoidosis or Guillain-Barre syndrome
• Tumor
• Lyme disease
• Multiple sclerosis
• Stroke (8)

Complications of Bell’s Palsy

Investigation

Electromyography – of prognostic importance:

(a) If signs of denervation after 10 days – Axonal degeneration, recovery either incomplete or delayed.

(b) If incomplete denervation in less than 7 days – Good prognosis.

(c)Fibrillation potential after 2 weeks suggests Wallerian degeneration. [1]

Treatment

Symptomatic measures include

(1) The use of paper tape to depress the upper eyelid during sleep and prevent corneal drying.

(2) Massage of the weakened muscles.

A course of glucocorticoids, given as prednisone 60–80 mg daily during the first 5 days and then tapered over the next 5 days, modestly shortens the recovery period and improves the functional outcome. Although large and well controlled randomized trials found no added benefit of the antiviral agents valacyclovir (1000 mg daily for 5–7 days) or acyclovir (400 mg five times daily for 10 days) compared to glucocorticoids alone,

combination therapy

some earlier data suggested that combination therapy with prednisone plus valacyclovir might be marginally better than prednisolone alone, especially in patients with severe clinical presentations. For patients with permanent paralysis from Bell’s palsy, a number of cosmetic surgical procedures have been used to restore a relatively symmetric appearance to the face. [1]

Prevention of Bell’s Palsy

Here, can not provide specific measures for the prevention of Bell’s palsy. This is because the exact cause of the condition remains unclear, although reactivation of herpes simplex virus type 1 (HSV-1) is considered a likely factor.

Homeopathic Treatment of Bell’s palsy

Homeopathy treats the person as a whole. It means that homeopathic treatment focuses on the patient as a person, as well as his pathological condition. The homeopathic medicines selected after a full individualizing examination and case-analysis.

Which includes

• The medical history of the patient,
• Physical and mental constitution,
• Family history,
• Presenting symptoms,
• Underlying pathology,
• Possible causative factors etc.

A miasmatic tendency (predisposition/susceptibility) also often taken into account for the treatment of chronic conditions.

What Homoeopathic doctors do?

A homeopathy doctor tries to treat more than just the presenting symptoms. The focus is usually on what caused the disease condition? Why ‘this patient’ is sick ‘this way’?

The disease diagnosis is important but in homeopathy, the cause of disease not just probed to the level of bacteria and viruses. Other factors like mental, emotional and physical stress that could predispose a person to illness also looked for. Now a days, even modern medicine also considers a large number of diseases as psychosomatic. The correct homeopathy remedy tries to correct this disease predisposition.

The focus is not on curing the disease but to cure the person who is sick, to restore the health. If a disease pathology not very advanced, homeopathy remedies do give a hope for cure but even in incurable cases, the quality of life can greatly improve with homeopathic medicines.

Homeopathic Medicines for Bell’s palsy:

The homeopathic remedies (medicines) given below indicate the therapeutic affinity but this is not a complete and definite guide to the homeopathy treatment of this condition. The symptoms listed against each homeopathic remedy may not be directly related to this disease because in homeopathy general symptoms and constitutional indications also taken into account for selecting a remedy, potency and repetition of dose by Homeopathic doctor.

So, here we describe homeopathic medicine only for reference and education purpose. Do not take medicines without consulting registered homeopathic doctor (BHMS or M.D. Homeopath).

Medicine:

Causticum:

• This remedy also has paralysis from exposure to the cold of winter.
• Facial paralysis from exposure to dry cold weather. Cowperthwaite published a large number of cases of facial paralysis cured with Causticum 30, and its value in this affection seems established.
• It has also paralysis of single parts, face, tongue, pharynx, etc.

Gelsemium:

• Complete motor paralysis, rather functional than organic in origin. It is one of our best remedies in post-diphtheritic and in infantile paralysis.
• Paralysis of the ocular muscles, ptosis; the speech is thick from paretic conditions of the tongue.
• Paralysis from emotions. Aphonia, paralysis of the larynx.

Aconite:

• Complete motor paralysis, rather functional than organic in origin. It is one of our best remedies in post-diphtheritic and in infantile paralysis.
• Paralysis of the ocular muscles, ptosis; the speech is thick from paretic conditions of the tongue. Paralysis from emotions.
• Aphonia, paralysis of the larynx.

Conium:

• Palsy of old people esp. old women. "Conium may be useful in paralysis, especially partial, the patient being weak and continuously trembling; the limb continually trembling; the limbs give out when walking and he falls forward; sudden attacks of giddiness and faintness.
• "Palsy after concussion of spine.

Bryonia:

• Abnormal hunger, loss of taste.
• Dryness of mouth, tongue also throat with excessive thirst.
• Especially, Tongue coated yellowish, dark brown; heavily white in gastric derangement. At last, Lips swollen, dry cracked.

Pulsatilla:

• Dry mouth without thirst.
• Crack in middle of lower lip. Offensive odour from mouth. Frequently licks dry lips. Loss of taste.
• Besides this, Alteration of taste, bitter, bilious, greasy, salty, foul. [5]

Diet & Regimen

• Avoid hard, chewy foods as these can be difficult to prepare and choose a soft easy chew diet such as pasta dishes, fish, well cooked meats and vegetables.
• Try smaller mouthfuls as these are easier to control and less likely to spill from your mouth.
• If your mouth is dry then make sure your food is moist by adding extra butter, gravy or sauces.
• Brush your teeth after meals to ensure no food debris is left behind or trapped inside your cheek. You may need to use your finger to clear any food debris from your cheek. It is important to do this in order to avoid tooth decay. [4]

Terminology

Medical Terms

• Acute: Refers to a condition that begins abruptly and develops rapidly.
• Idiopathic: Means a disease or condition with an unknown cause.
• Lower motor neuron: A type of nerve cell that directly controls muscle movement. In Bell’s palsy, these neurons in the facial nerve are affected.
• Facial palsy: Weakness or paralysis of the muscles in the face.
• Monophasic: A disease or condition that occurs in one phase or episode.
• Self-limited: A condition that resolves on its own without specific treatment.
• Etiology: The cause of a disease or condition.
• Geniculate ganglion: A cluster of nerve cell bodies located on the facial nerve.
• Labyrinthine segment: The first and narrowest part of the facial canal through which the facial nerve passes.
• Ischemia: A lack of blood flow to a tissue or organ.
• Herpes simplex virus type 1 (HSV-1): A common virus that causes cold sores and is often implicated in Bell’s palsy.
• Varicella zoster virus: The virus that causes chickenpox and shingles, also a potential cause of Bell’s palsy.
• Autoimmune: A condition in which the body’s immune system attacks its own tissues.
• Hyperacusis: Increased sensitivity to sound.

Homeopathic Terms

• Miasm: In homeopathy, a miasm refers to a predisposition to certain diseases, believed to be inherited.
• Potency: The strength or dilution of a homeopathic remedy.
• Repetition: How often a homeopathic remedy is taken.
• Therapeutic affinity: The tendency of a homeopathic remedy to act on specific organs or systems in the body.
• Constitutional indications: The physical and mental characteristics of a person that guide the selection of a homeopathic remedy.

Additional Terms

• Epidemiology: The study of the distribution and determinants of health-related states or events (including disease), and the application of this study to the control of diseases and other health problems.
• Pathogenesis: The development of a disease or morbid condition.
• Pathophysiology: The functional changes associated with or resulting from disease or injury.
• Differential diagnosis: The process of distinguishing a particular disease or condition from others that present similar clinical features.

References 

1. Harrisons_Principles_of_Internal_Medicine_19th_Edition-2, Volume_Set
2. Medicine Golwala
3. Davidsons Principles and Practice of Medicine (PDFDrive.com)
4. Medical Nutrition Therapy_ A Case Study Approach (PDFDrive)
5. The Homoeopathic Prescriber by K. C. Bhanja
6. https://www.asterhospitals.in/blogs-events-news/aster-medcity-kochi/bells-palsy-symptoms-causes-and-risk-factors
7. Bell’s palsy physical examination – wikidoc afp.org/pubs/afp/issues/2007/1001/p997.html
8. Singh, R., & Singh, S. (2014). Clinical profile and outcome of Bell’s palsy in a rural setting in India. Journal of Neurosciences in Rural Practice, 5(4), 381-385.