Bell's Palsy Diagnosis

Bell's Palsy Diagnosis
      The diagnosis of Bell's palsy can be established by anamnesis and physical examination, in which case the neurological examination. To establish a diagnosis of Bell's palsy should be established first, the type of peripheral facial paresis, then get rid of all the possible causes facial paresis. Peripheral facial paresis is different, from the central type.
In the central type of disturbed or paresis only on the bottom of the face only. It should be also distinguished between UMN (Upper Motor Neuron) and LMN (Lower Motor Neuron) lesions. Bell's palsy is LMN lesions.

A. Anamnesis.
      Almost all patients brought to the emergency room to feel that they have suffered a stroke or intracranial tumor. Almost all complaints are weakness on one side of the face.
What are need to be asked in anamnesis?
1. Pain.
Postauricular pain: Nearly 50% of patients suffering from pain in the mastoid region. Pain often appear simultaneously accompanied by paresis, but paresis appeared in 2-3 days at about 25% of patients.
2 Impaired or loss of taste.
Changes in taste: Only a third of patients complain about the taste sensation disorders, four-fifths of patients showed a decrease in flavor. This happens because  only half of the tongue is involved.
3. Disturbance in the eyes
• The flow of tears: Two-thirds of the patients complained about the flow of their tears. It is caused by a reduction in the orbicularis oculi drain tears. Only a few tears to flow up and over-saccus lacrimal fluid. Tear production is not accelerated.
• Dry eye.
4. History of the work and is there any activity conducted at night outdoors.
5. History of disease experienced by patients with respiratory tract infections, otitis, herpes, and others.
6. Hyperacusis: damage tolerance to a certain extent on the nose due to increased irritability mechanisms of sensory neurons.

B. Physical examination.
       Clinical manifestations of facial paralysis is easily recognizable on physical examination. Full and proper examination to rule out other possible causes of facial paralysis. Think of other etiology if all branches of the facial nerve was not impaired.
      - The classic definition, Bell palsy describes mononeuron involvement of the facial nerve, although other cranial nerves may also be involved. The facial nerve is the only cranial nerve that shows a picture of disorder on physical examination as it travels from the brain to the facial anatomic lateral section.
      - weaknesses or paralysis of the facial nerve disorders due to appear as a weakness of the face (upper and lower) on the side of being attacked. Note the voluntary movement on the part of the face being attacked.
      - In supranuclear lesions such as cortical stroke (upper motor neuron, on top of the facial nucleus in the pons), where the upper third of the face experiencing weakness and the lower two-thirds experiencing paralysis. Musculus orbicularis, frontalis and corrugator innervated bilaterally, so that they can understand the patterns of facial paralysis.
       - Perform other cranial nerves: the results of the examination is usually normal.
     - Tympanic membrane should not be inflamed; infection appears to increase the possibility of otitis media with complications.

1. Neurological examinations
Facial nerve palsy involving all one side facial muscles and can be proved by examinations of the following, namely:
a. Examination of the facial nerve motor.
- Frowning: forehead skin folds appear only on the healthy side only.
- Raising eyebrows: eyebrows on the affected side can not be raised
-  Closing eyes firmly: on the affected side, the lids can not cover the eye, and turning his eyes to the top can be seen. This phenomenon is known Bell. Moreover, it can be seen also that the diseased eyelid movements slower than the healthy eyelid movement, this is known as Lagophtalmus.
- Inflating the cheek: the unhealthy side, cheek can not be inflated.
- Patients were asked to separately show the gear teeth or ordered grimacing grin: the corners of the mouth were paralyzed, can not be lifted so that the mouth seems lopsided toward healthier side. And also  nasolabialis sulcus on the flat face of the sick.
b. Sensory examination of the facial nerve.
      Taste Sensation examined as follows: the sweet taste on the tip of the tongue checked with materials such as salt, and sour taste in the middle of the tongue examined with citric acid materials. The tasting 2/3 front of the tongue: taste the unhealthy side less sharp.
c. Reflex examination.
        Reflex examination conducted in patients with Bell's palsy, is an examination of the corneal reflex, either directly or indirectly, where the VII nerve paresis on the results obtained in the form of a blink of an eye sore that occurs more slowly or not at all. It can also be checked nasopalpebra reflex in healthy people by tapping fingertips on the area between the eyebrows immediately answered with eyelid closure on the side, while the type of peripheral facial paresis there are weaknesses contraction. orbicularis oculi (eye closure on the affected side).
d. Some other simple checks that can be implemented to help enforce the diagnosis include:
- Stethoscope Loudness Test
This examination can be used to assess the function of the muscular stapedius. Patients were asked to use a stethoscope then sounded a tuning fork on the membrane stethoscope, then a loud voice will be heard into the muscular stapedius, which paralyzed
- Blotting Schirmer Test.
This examination is used to assess the function of lacrimation. Used benzene nasolacrimalis thus stimulate reflex tears than comparable between the paralyzed and normal.

C. Laboratory examination.
        There is no specific laboratory test for the diagnosis of Bell's palsy. However, examination of blood glucose or HbA1c may be considered to determine whether patients had diabetes or not. Examination of serum HSV can also be done, but this is usually not able to determine where the virus originated.

D. Radiological examination.
       If from the anamnesis and physical examination has led to the diagnosis of Bell's palsy is the radiological examination is not necessary anymore, because patients with Bell's palsy will generally experience an improvement in 8-10 weeks. If there is no improvement or had worsening, imaging may be helpful. Radiological examinations can implemented to Bell's Palsy include MRI (Magnetic Resonance Imaging) which in patients with Bell palsy can occur in the facial nerve abnormalities. Besides MRI examination is also useful if the patient experienced recurrent facial paralysis, in order to ascertain whether the disorder is only a disorder or are on the facial nerve tumor. MRI may show a tumor (eg, schwannoma, hemangioma, meningioma). If the patient has a history of trauma so a CT scan should be performed.


•    Bell's Palsy 
•    Etiology and Pathophysiology of Bell's Palsy 
•    Clinical Manifestations of Bell's Palsy 
•    Medical Treatment and Therapy of Bell's Palsy 
•    Complications and Prognosis of Bell's Palsy


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