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Friday, 6 April 2012

PLASTIC / Oncologic Surgery SERIES: THE DISTINGUISHING Bell's palsy with Iatrogenic paralise of the facial nerve (etiology, SIGN-symptoms, DIAGNOSIS AND MANAGEMENT)

PLASTIC / Oncologic Surgery SERIES: THE DISTINGUISHING Bell's palsy PARALISE iatrogenic facial nerve (etiology, SIGN-symptoms, DIAGNOSIS AND MANAGEMENT)

The term Bell's palsy is a peripheral facial nerve paresis of unknown cause (idiopathic) and acute. Many are mixed up between Bell's palsy with peripheral facial nerve paresis other unknown causes.
Bell's palsy is found, usually people with facial paralysis learn from friends or family or at the mirror or brush teeth / rinsing. When the patient realizes that he is paralyzed on her face, then he began to feel fear, shame, low self-esteem, cosmetic and sometimes disturbing soul depressed, especially in women and in patients who have a profession that requires him to appear in public. Often the question arises in his heart, if his face could go back to normal or not.

from wikipedia picture
 from freedictionary.com

from holistik magazine

 By definition: Bell's palsy is a paralysis of the facial peripheral cause is unknown, could be due to the non-suppurative, non-neoplasmatik, non-degenerative primers, but is probably due to edema benign on the facial nerve in the foramen stilomastoideus or slightly proximal to the foramen, which Initially acute and can heal itself without treatment.


Bell's palsy affects about 30,000 - 40,000 people a year in the United States.

Bell's palsy involves damage to the seventh cranial (facial) nerve. This nerve controls the movement of the muscles of the face.

 Paralise the facial nerve is often due to trauma or injury around the face preauriculer or there is also a history of surgery on the parotid gland (classical case) Parotidectomy superficial, other salivary gland surgery, facial surgery about preauriculer, jaw surgery and ENT surgery area around the canal acoustic externus or around the foramen stilomastoideus or slightly proximal to the foramen.

Data In Indonesia, the incidence of Bell's palsy is certainly difficult to determine. Data collected from the 4 hospitals in Indonesia the frequency of Bell's palsy for 19.55% of all cases of neuropathy and the highest at ages 21-30 years. More common in women than men. Found no difference in incidence between hot and cold climates, but in some patients obtained a history of exposure to cold air or excessive wind.


Until now many controversies regarding the etiology of Bell's palsy, but there are 5 theories associated with the etiology of Bell's palsy are:
1. Ischemic vascular theory
 When the facial nerve may be paralyzed due to an indirect regulation of blood circulation disorders in the facial canal.
2. Theory of virus infection
The virus is often considered most responsible for the Herpes Simplex Virus (HSV), which occurs due to the reactivation of HSV (especially type 1). The virus can be Nested in the nerve ganglion.
3. Theory of hereditary
Abnormalities of Bell's palsy may occur due to the narrow facial canal in the offspring or the family, thus causing predisposition to the occurrence of facial paresis.
4. Immunological theory
The state of Bell's palsy occurs due to immunological reactions to viral infections that occur before or prior to immunization.
5. mixture theory, a variety of factors and conditions that influence it.


To understand the disorder Bell's palsy, we must understand the anatomy, physiology of the body.

But whatever the etiology of Bell's palsy, which is considered the end of the process responsible for the clinical symptoms of Bell's palsy is the process of edema which in turn causes compression of the facial nerve. The first is a disturbance or damage to the endothelium of the capillaries to edema and increased capillary permeability, capillary leak that may occur later in the surrounding tissue edema and blood flow interruption will occur resulting in hypoxia and acidosis that result in cell death. Damage to these cells resulted in the presence of proteolytic enzymes, formation of toxic peptides and the activation of the kinin and kallikrein as the destruction of the nucleus and lysosomes. If allowed to permanent tissue damage.


Bell; s palsy usually occur suddenly, the patient is aware of the paralysis on one side of his face to wake up, looked in the mirror or when brush gig / rinse or informed by other people / family that one of the lower corners. Bell's palsy is almost always unilateral. Clinical picture could be loss of all voluntary movement in total paralysis. On the affected side of the face, the expression will disappear so that the creases will disappear nasolabialis, corner of mouth down, when to drink or rinse water is dripping from the corners, the eyelids can not be screwed so papebra widening fissure and forehead wrinkles disappear. If the patient is told to close my eyes then the eyelid on the paralyzed side will remain open (called lagoftalmus) and spins up eyeballs. This situation is known as the sign of the Bell (lagoftalmus accompanied dorsorotasi eyeball). Because of the reduced eye blink there will be irritated by dust and wind, giving rise to epifora.1, 6 In sweelling cheek seen that on the paralyzed side is mengembung.6 Besides food tends to collect between the cheek and gum side lumpuh.1 addition to paralysis sesisi all facial muscles, found no other problems accompanying, when paresis appear, really is "Bell's palsy".

Diagnosis is based on anamnesis and a physical examination, in which case the neurological examination.
A. Anamnesis:
- Pain.
- Disturbance or loss of taste.
- History of the work and activities carried out there at night in open space or outdoors.
- History of disease experienced by patients with respiratory tract infections, otitis, herpes, and others.
2. Examination:
- Neurological examination found N.VII paresis of peripheral type.
- Voluntary movement is examined, it is recommended a minimum:
A. Frowned
2. Close my eyes
3. Develop nostril
4. Smile
5. Whistle
6. Tighten the two lips
To evaluate the progress of patients with Bell's palsy motor using SCALE Ugo Fisch
SCALE Ugo Fisch
Assessed the condition of symmetric or asymmetric between the healthy and the sick at the 5 position:

Assessment percentages:
- 0%: asymmetric complete, there is no voluntary movement
- 30%: symmetrical, poor / poor, healing the existing asymmetries closer to complete than normal symmetrical.
- 70%: symmetrical, fair / insufficient, partial recovery is likely in the direction normal
- 100%: symmetrical, normal / complete
3. Clinical diagnosis: N.VII upheld by the peripheral paresis and not central. Generally unilateral
4. Diagnosis Topic:

5. Etiologic diagnosis: To date the etiology of Bell's palsy which is obviously unknown.
6. Differential diagnosis:
A. Otitis Media and Mastoiditis supurativa
2. Herpes Zoster Oticus
3. Trauma capitis
4. Guillain - Barre
5. Myasthenia Gravis
6. Tumor Intrakranialis

Heal spontaneously in 75-90% within a few weeks or within 1-2 months. Approximately 10-15% of them will give you an idea of ​​permanent damage.


A. That phenomenon Crocodile tear tears when people eat food. These occur several months after the paresis and the effect of regeneration is one of the supposed autonomic fibers to the salivary gland, but leading to the gland lakrimalis. Location of lesions in the ganglion genikulatum. ¬ 1
2. Synkinesis. In this case the muscles can not be moved one at a time or separately; always occur with movement. For example if the patient is told to close my eyes, then there will be movement (involuntary) elevation angle of the mouth, contraction platisma, or berkerutnya forehead. Innervasi cause is wrong, regenerating nerve fibers connected with the muscle fibers are wrong.
3. Hemifacial spasm. Arises "twitch" on the face (facial muscles move spontaneously and uncontrolled) and facial muscle spasms, usually mild. In the early stages only on one side of the face, but then be on the other side. Fatigue and psychological disorders can aggravate these spasms. This complication occurs when the healing is not perfect, which occurs within a few months or 1-2 years later.
4. Contractures. It can be seen from the attraction of the muscle, so the folds nasolabialis more clearly visible on the paralyzed side than on the healthy side. Occurs when the return function is very slow. Contracture did not appear at the time of the facial muscles a rest, but becomes apparent when the facial muscles move.


a) Medical treatment: Group of corticosteroids is still controversial, also can be neurotrophic.
b) Operative Treatment: Surgical decompression remains controversial
c) Medical Rehabilitation
Medical rehabilitation according to the WHO are all actions that are aimed to reduce the impact of disability and handicap and to improve the ability of people with disabilities to achieve social integrity.
Medical rehabilitation objectives are:
A. Negate disability when possible
2. Reduce disability as much as possible
3. Train people with disabilities the rest of the state agency to be able to live and work with what is left.
To achieve success in the goal of effective and efficient rehabilitation will require medical rehabilitation team consisting of doctors, physiotherapists, occupational therapists, prosthetic ortotis, speech specialists, psychologists, social workers and medical nurses medical rehabilitation.
In accordance with the concept of medical rehabilitation is a joint effort integrated in terms of medical, social and workmanship, then the purpose of medical rehabilitation in Bell's palsy is to reduce / prevent paresis to grow and help solve social problems and psychology so that people can still carry out activities of daily activities. The programs are administered is a program of physiotherapy, occupational therapy, medical social, psychological and orthotic prosthetic, is a program of rehabilitation nurses and speech therapy are not a lot to do.

Physiotherapy Program
- Warming
A. Superficial heating with infra red.
2. Heating in the form or Microwave Diathermy Shortwave Diathermy
- Electrical stimulation
Purpose of providing electrical stimulation to stimulate the muscles to prevent / slow the atrophy occurs while waiting for the regeneration and strengthening the muscles that are weak. For example, by faradisasi whose purpose is to stimulate muscle re-education of muscle action, train new muscle function, improving circulation and prevent / stretch the adhesions. Given 2 weeks after onset.
- Exercise the facial muscles and facial massage
Voluntary facial muscle movement exercises given after the acute phase. Exercise in the form of raised eyebrows hold 5 seconds, frowning, close your eyes and lift the corners of the mouth, smiling, whistling / blowing (done in front of the glass with full concentration).
Massage is the manipulation of scientific sitemik and body tissues in order to repair / recovery. In the acute phase, Bell's palsy were given gentle massage slowly and rhythmically. Gentle massage gives the effect of reducing edema, muscle relaxation and maintaining otot.1 tone, 3 Once past the acute phase of the Deep Kneading Massage given prior to exercise voluntary movement of facial muscles. Deep Kneading Massage to the mechanical effects of venous blood and lymph vessels, launched the disposal of metabolic, lactic acid, reducing edema, improving nutrition muscle fibers and thus enhance intramuscular movement perlengketan.11 Massage releases the facial area is divided into four areas of the chin, mouth, nose and forehead. All the movements are directed upward, the length of 5-10 minutes.

Occupational Therapy Program
Basically here to give exercise movement therapy on facial muscles. Exercises given in the form of daily activities or in the form of the game. Keep in mind that exercise gradually and see the condition of the patient, the patient should not be exhausting. Exercise can be rinsed exercise, workout drink with a straw, blow the candle practice, practice closing your eyes and frowning in the mirror.

Medical Social Program
Bell's palsy sufferers often feel ashamed and withdraw from social interaction. Social problems usually associated with the workplace and cost. Medical social worker can help solve by calling the workplace, may temporarily be able to work on parts that are not much related to the public. To cost issues, assisted with finding health care facilities in the workplace or through family. Besides providing information that cooperation with workers treating patients is essential for healing the patient.
Psychological Program
For certain cases where there are very prominent psychic disturbances, anxiety often accompany the patient, especially in young people, women or people who have a profession that requires that he often appeared in public, then the help of a psychologist is required.
Orthotic programs - Prosthetics
Installation can be done "Y" plaster corners of the mouth in order not to fall ill. It is recommended that the plaster be replaced every 8 hours. It should be noted that skin intolerance reactions are common. Installation of "Y" if the plaster be done within 3 months there has been no change in patients after undergoing physiotherapy. This is done to prevent teregangnya zygomaticus muscle during parese and prevent contractures.
Home Program:
A. Warm compresses the diseased side of the face for 20 minutes
2. Massage the sore face upward by hand from the face of a healthy
3. Inflatable exercise wax, rinse, eat with a sore hand chewing, drinking through straws, chewing gum
4. Eye care:
A. Give eye drops (group artifial tears) 3x a day
2. Wearing dark glasses when traveling during the day, and the habit passively closed eyelids before bed.

Operative action

When the cause of paralysis is known, especially the iatrogenic operative action considered. performed to repair the nerve. the speed of nerve healing is an average of 1 mm per day

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