PnsTx 400 - Bell's Palsy/ Trigeminal & Glossopharyngeal Neuralgia

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Terms in this set (...)

Cranial Nerves
Define:
1. Neuropathy
2. Palsy
1. disease or dysfunction of PNS, typically causing numbness or weakness.
2. paralysis, especially that which is accompanied by involuntary tremors.
Define Bell's Palsy:
-Paralysis of Facial nerve (CN VII), causing muscular unilateral weakness on one side of face
• 20 out of approx. 100,000/yr
• MC b/t 20-40 yrs
Is Bell's Palsy an UMN or LMN lesion?
LMN
Branches and innervation of Facial nerve:
1. Temporal branch to orbital mm (except levator palpebrae superioris)
2. Zygomatic branch goes to the zygoma, orbital and intraorbital area
3. Buccal branch to all buccinator mm and upper lip
4. Mandibular branch to lower lip and chin mm
5. Cervical branch to platysma, stylohyoid, posterior digastric mm.
6. Posterior Auricular branch supplies occipitalis mm
Branches and Facial nerve image:
Gland that Facial nerve passes through but does not innervate:
Parotid Gland
Causes Bell's Palsy:
Various
- Viral/Infection/Inflammation
- Facial/surgical wounds
- Trauma/Temporal bone Fx
- Brain stem injuries
- Acoustic neuromas, parotid tumors
- Metabolic/Systemic
M/C Viral/Infection cause of Bell's Palsy:
- MCC: HSV-1 (60-70%)
- Other: Cytomegalovirus, Epstein-Barr, rubella & mumps (parotid gland)
What are the Metabolic/Systemic contributors to Bell's Palsy:
- Pregnancy compression
• 3rd trimester
• Resolves postpartum
• 45/100,000

-DM
4 x's as likelyy* as general population
How to recognize difference b/w Bell's Palsy & Stroke:
Bell's = paralysis entire side of face (ipsilateral to lesion)

Stroke = paralysis lower 1/2 of face + body + speech (contralateral to lesion)
Why is there a difference b/w Bell's & Stroke w/ facial paralysis?
- forehead receives corticobulbar fibers from both contra/ipsi motor cortex
- lower face receives corticobulbar fibers from only contra motor cortex
- Stroke affects motor stimuli @ source on only 1 side of cortex = only lower 1/2 face contralateral to lesion
- Bell's is PNS so nerve is affected after decussation = entire 1/2 face ipsilateral to lesion
Pathogenesis Bell's Palsy:
• Mononeuropathy
• Inflammatory response
• Axonal degeneration
- Muscles become temporarily weakened or paralyzed.
• Tumor (e.g. Acoustic) cause paralysis unilaterally as facial nerve emerges from brain stem.
How is speech affected w/ Bell's & Stroke?
Bell's = Minor Dysarthria due to facial mm paralysis. No Dysphagia.
Stroke = Speech affected at cerebral level, may experience Dysphagia (Fluent or Nonfluent) + Dysarthria
What are the stages of stroke:
1st stage: <72 hours = flaccid
2nd stage: >72 hrs = spasticity, synergy, speech
S&S Bell's Palsy:
• Only facial tissue/gland paralysis involved w/ no mental func impairment
• Unilateral/Asymmetric
• Rapid progression
• Muscle weakness or paralysis
• Forehead wrinkles disappear/ Brow drop
• Overall droopy appearance
• Impossible or difficult to blink
• Nose runs & constantly stuffed
• Difficulty speaking
• Difficulty eating and drinking
• Sensitivity to low tones (hyperacusis)(stapedius mm)
• Excess or reduced salivation (autonomic)
• Facial swelling
• Pain in or near the ear
• Drooling
• Lack of or Excessive tears (autonomic)
• Lower eyelid droop
• Sensitivity to light
Loss taste ANT 2/3's tongue
What other conditions are included in DDx w/ Bell's Palsy?
-Lyme's Disease
-Tumors
-Stroke
Bell's Palsy Observations:
■ Facial expression distortions
■ Head may be positioned in a way to hide
■ Sometimes hand or hair is used to cover affected side
■ Tearing may be seen
■ Eye Patch
Tx for Bell's Palsy:
• First priority in treating - eliminate source
• Wear tinted lenses
• Rest & moist heat
• Meds relieve compression/infection (Prednisone & antivirals) limited data
• Massage or tapping can provide gentle stimulation w/out risk plus incr. circulation (OK IF NO INFECTION)
Why would we not want to encourage immediate exercise w/ Bell's Palsy?
flaccid tissue can create imbalance w/ TMJ
Tx considerations for Bell's Palsy:
• Position: Supine - Towel available for tearing & drooling
• Towel btw therapist & affected side (protect tissue)
• Hydro - warm cloth on affected area for short period
- cool washes on affected tissues
- local heat over affected side to treat trp unless application will increase edema
(NO WARM HYDRO w/ EDEMA/INFECTION)
Tx details Bell's Palsy:
• **NO FASCIALL***
• Always block to protect affected tissues (↓ DRAG)
• Encourage diaphragmatic breathing
• Start on unaffected side w/ strokes TOWARD affected side
• Work anterior chest, posterior neck, shoulders, anterior neck (careful with platysma, tractioning in early stages) - strokes toward affected
• Lymph drainage
• Gentle ROM on TMJ and C spine
Home care Bell's Palsy:
• Sleep with eye patch
• Facial expressions in mirror
- Sniffle, wrinkle nose, flared nostrils, curl upper lip, protrude upper lip, compress lips together, pucker lips, smile w/ and without teeth
- *FIDS:* 2-3 xs/day for 5Xmins while watching in mirror & gradually ↑ w/ progression
• Hydro: cool cloth before exercise to stimulate areaa* - moderate moist heat for pain relief
-Neuralgia involving one or more of branches of CN V, and often causing severe pain
-Not fatal but often leads to suicide if untreated
Trigeminal Neuralgia
aka: Tic Douloureux
Functions of Trigeminal Nerve:
MOTOR & SENSORY
- Tactition (pressure sensation)
- Thermoception (temperature)
- Nociception (pain)
- Muscles of mastication
- 3 divisions
What are the 3 divisions of the Trigeminal nerve?
V1. Opthalmic = superior orbital fissure
V2. Maxillary = foramen rotundum
V3. Mandibular = foremen ovale
Etiology Trigeminal Neuralgia:
• Est 5/100,000
• >50 years
• F = M
• Aneurysm
• Tumor
• Arachnoid cyst in cerebellopontine angle
Multiple sclerosis incr riskk* (greater risk in Men w/ MS)
• Traumatic (MVA or tongue piercing)
What pathology is Trigeminal Neuralgia commonly seen w/ in men?
Multiple sclerosis
Pathogenesis Trigeminal Neuralgia:
-Superior Cerebellar Artery compression @ connection w/ Pons
-Causes Neuropraxia/Axonotmesis
-Hyperactivity of Trigeminal n. nucleus
Clinical manifestations Trigeminal Neuralgia:
• Episodes of intense pain occur paroxysmal (suddenly)
• Trigger zones
• Ipsilateral
• Can last seconds or longer
• Can be 100's of times day
- Cycles w/ complete remissions lasting months or even years.
Common triggers of Trigeminal Neuralgia:
- Shaving
- Stroking your face
- Eating
- Drinking
- Brushing your teeth
- Talking
- Putting on makeup
- Encountering a breeze
- Smiling
Dx Trigeminal Neuralgia:
• No single medical test
• DDx to rule out other causes
No sensory or motor loss (sensation testing not recommended)
• Special x-ray images, such as a CT scan or MRI of head, can look for other causes of facial pain
What is clinically relevant with sensation in regards to Trigeminal Neuralgia?
There is NO loss of sensory or motor function
(sensory testing could elicit a painful response)
Treatment Trigeminal Neuralgia:
NO CURE
Conservative:
- Massage b/t attacks (avoid trigger zones)
- Relief from medication
- Ice areas of Pain
- Get rest/sleep
- Diet & Exercise
- Tx supine, no face in cradle. Decr SNS, no stimulatory or painful tech's

Invasive:
- Surgery to relieve pressure on nerve
- Selective damage to nerve to disrupt pain signals
-Irritation of CN IX causing extreme pain in back of throat, tongue and ear
-Attacks of intense, electric shock-like pain can occur w/o warning or can be triggered by swallowing.
Glossopharyngeal Neuralgia
Anatomy/Func of Glossopharyngeal Nerve:
• CN IX
• Arises medulla oblongata
• Emerges at Jugular Foramen
1. Branchial motor (special visceral efferent)
2. Visceral motor (general visceral efferent)
3. Visceral sensory (general visceral afferent)
4. General sensory (general somatic afferent)
5. Special sensory (special afferent)
Etiology/Risk Factors Glossopharyngeal Neuralgia:
• Idiopathic
• > 40 years of age
• Rare pain syndrome
• Compression throat & mouth (Tumors, Infections, Blood vessels)
What disease is Glossopharyngeal Neuralgia associated with?
Multiple Sclerosis (MS)
Pathogenesis Glossopharyngeal Neuralgia:
• Mononeuropathy
• Compression = Neuropraxia
Dx Glossopharyngeal Neuralgia:
• X-rays
• CAT scan
• MRI (inflammation CN IX)
• Magnetic resonance angiography (MRA)
• Cardiac arrhythmia's & even asystole w/ attack of pain
DDx Glossopharyngeal Neuralgia:
Glossopharyngeal tic is sometimes mistaken for mandibular division trigeminal tic douloureux
Tx Glossopharyngeal Neuralgia:
Conservative:
- Controlling pain
- Massage
- Nutrition
- Anti-seizure medications (carbamazepine, gabapentin)

Invasive/Surgery
- Decompression CN IX
Prognosis Glossopharyngeal Neuralgia:
• Some individuals recover from an initial attack & never have another
• Others will experience clusters of attacks followed by periods of short/long remission.
What Neuralgia may result in weight loss or nutritional deficiencies 2° to the condition itself?
Trigeminal Neuralgia
Glossopharyngeal Neuralgia

• Individuals may lose weight if they fear that chewing, drinking, or eating will cause an attack
Important points to remember b/w Stroke, Bells Palsy & Trig/Glosso Neuralgia:
-Stroke affects low 1/2 of face contralateral to lesion as upper 1/2 face receives innervation from both sides of cortex
-Bell's is paralysis of Facial nerve ipsilateral to lesion and affects entire 1/2 of face since Facial n. is part of PNS
-Trig/Glosso are neuralgia, extreme pain with no loss of sensory/motor func
-Trig/Glosso must have extreme caution w/ Tx to avoid a trigger