Students Corner Osteopathic manipulative treatment of Bells palsy by Robert F.Ulrich, MS-Ill, University of North Texas Health Sciences at Fort Worth/TCOM Introduction sagging of the lower lid which allows expression are affected. If the lesion is Bell's palsy is defined as paralysis the punctum to fall away from the in the middle ear portion, taste is lost or weakness of the muscles supplied conjunctiva, resulting in tearing. The over the ipsilateral anterior two-thirds by the facial nerve (CN VII) due to site of the lesion determines the clinical of the tongue. If the nerve to the inflammation and swelling of the presentation, so it is necessary to focus stapedius is interrupted, the patient nerve within the facial canal. It is on the anatomy of the facial nerve. experiences hyperacusis (painful almost always unilateral, most sensitivity to loud sounds) and may common in people over the age of Anatomy experience unilateral ear pain. Lesions thirty, and affects approximately 1 in CN VII is primarily motor, in the internal auditory meatus can 65 people over the course of a lifetime. supplying the muscles of facial also affect adjacent auditory and A diagnosis of Bell's palsy implies an expression and muscles of the scalp, vestibular nerves causing deafness, idiopathic cause, but antecedent auricle, buccinator, platysma, tinnitus, or dizziness. factors include exposure to cold or stapedius, stylohyoid, and the posterior viruses, and head trauma. Associated belly of the digastric. It has a small Case Presentation diseases include the Ramsay Hunt sensory component (nervus The patient is a 39-year-old white syndrome, which is Bell's palsy along intermedius) which conveys taste female who initially presented to the with vesicles in the external auditory sensation from the anterior two-thirds core clinic in March 1997, with a chief canal or behind the auricle and is due of the tongue and cutaneous sensation complaint of chronic right ear pain to herpes zoster infection of the from the anterior wall of the external which she described as a "deep ache." geniculate ganglion. Bilateral facial auditory canal. It also supplies She also complained of a feeling in her paralysis is highly unusual and should parasympathetic secretory stimulus to right ear "like a broken speaker" prompt a search for conditions such the submandibular, sublingual, and approximately once a day, aggravated as Guillian-Barre syndrome orchronic lacrimal glands. The facial nerve by noisy environment; and of right meningitis. originates in the pons, where the motor facial weakness with right eye irritation nucleus is located. Upon leaving the when she became tired. She stated that Clinical Manifestations pons it enters the internal auditory all these symptoms were residual from Onset of Bell's palsy is fairly meatus with the acoustic nerve. It having Bell's palsy three years ago. At abrupt, occurring suddenly or over a courses through the middle ear in the the onset of her disease, she visited her few days with maximum weakness temporal bone where it gives off a family doctor and was placed on usually attained by 48 hours. Pain small branch, the nerve to the stapedius, NSAIDS with no relief of symptoms. behind the ear may precede paralysis which performs a dampening function. She suffered from complete unilateral by a day or two. CN VII supj lies all The nerve exits the skull at the facial paralysis for three months, at muscles of facial expression and this stylomastoid foramen, passes through which time she began to gradually is manifested clinically by drooping the parotid gland and subdivides into improve. During this time she also of the corner of the mouth, flattening five branches to provide the facial suffered from chronic right ear pain of skin creases and folds of the face muscles. and "crackling" in her ear which and forehead, inability to close the If the lesion is at the stylomastoid persisted until she visited the OMT eyelid on the affected side, and foramen, only the muscles of facial clinic. Trauma history was significant 28/AAO Journal Fall 1997 for being knocked unconscious by a regarding osteopathic manipulative paralysis had largely resolved, but the baseball as a child without any treatment for treatment of Bell's palsy, ear pain and dysfunctional hearing evidence of skull fractures. She although much anecdotal evidence continued to trouble her daily. Based disclosed that she had studied martial exists. Most documented evidence upon these symptoms, it is almost arts for a couple of years with points to an etiology of trauma. The certain that her CN VII was affected numerous falls. She also reported a most common somatic dysfunctions fairly high up in the facial canal. Head bad middle-ear infection reported are sphenobasilar trauma can result in shifts in position approximately 12 years ago which compression and external fixation of of the occiput and temporal bone, resolved with antibiotics. Physical the temporal bones. Trauma can easily resulting in dural tension, restriction examination at the time of her initial disrupt the "rocker bearing" of physiologic motion, and edema. In visit to the OMT clinic revealed a mechanism of the temporal jugular the limited space of the bony facial slight flattening of facial creases and surface on the occipital jugular canal, this can lead to ischemia and folds. Palpation of her skull revealed tubercle, which is in close eventually degeneration from absence of motion. She was diagnosed approximation to the facial nerve. In compression. This is essentially an with sphenobasilar compression and addition, any shifts of the temporal entrapment neuropathy. With the treated with supine-indirect-inherent bone can cause dural tension at the cranial treatment this patient received, force at the sphenobasilar symphysis internal acoustic meatus. Irritation of physiologic motion was restored, and condylar decompression with nerve roots can result in histamine tension was relieved from the nerve, good response. Since that time she release, which causes peripheral and she has obtained complete relief has visited the core clinic weekly and vasodilation, fluid exudation, and of her symptoms. Bell's palsy is a states that her ear problems have continued irritation. Somatic fairly common condition, one that improved tremendously. She now gets dysfunction of the sphenoid, occiput, practicing physicians are likely to see the "broken speaker" sound and ear and temporal bones; and restriction often. As osteopathic physicians, pain about once a week. The right of cervical and thoracic myofascial cranial treatment is an important side of her face still shows some elements inhibit lymphatic drainage. modality that can be used to provide evidence of crease flattening. On her The edema in the unyielding bony relief to these patients, particularly most recent visit (April 30, 1997) she canal results in a pressure neuritis when allopathic methods fail. reported no ear pain or hearing which manifests its symptoms problems over the previous week. depending on the location of the lesion Bibiliography as described earlier. Although there is I. Disorders of the Cranial Nerves. In: Treatment no OMT mentioned for specifically Harrison's Principles of Internal Medicine. Approximately 80 percent of cases treating Bell's palsy, it is implied that 12th edition. Wilson, JD et al, eds. 1991. 2078-2079. recover completely over a period of by restoring cranial motion, treating weeks to months. Traditional therapy any fixed restrictions of cranial bones 2. Magoun, HI. Entrapment Neuropathy of is primarily supportive and consists (particularly the temporals), and the CNS. Part II CN I-V, VI-V111. XII. of keeping the affected eye patched improving lymphatic drainage, the JAOA 1968, 67: 779-787. pressure on the facial nerve can be and moistened to prevent corneal 3. Osteopathic Considerations in Diagnosis decreased or eliminated and allow the drying and abrasions. Medical and Treatment. In: Foundations for treatment consists of starting nerve to function properly. Osteopathic Medicine. Ward, RC, ed. 1996, Prednisone 80mg po qd for three days p 530. and tapering this by 20mg every three Discussion 4. Practical Application of the Cranial days. Steroid treatment should begin The origin of the Bell's palsy of the Concept. In: Osteopathy in the Cranial immediately – there is little benefit in patient in this study was idiopathic, Field. Magoun,HI, ed. 1976, p 269. using steroids after four days. One but likely secondary to the head trauma author reports using high-voltage experienced as a child. Perhaps, the 5. Shrode, LW. Treatment of Facial Muscles Affected by Bell's Palsy with High- electrical stimulation of the facial ear infection as a young adult Voltage Electrical Muscle Stimulation. J muscles with successful results. contributed also. At the time she Manipulative Phsiol Ther 1993; 16(5): There is a paucity of literature visited the OMM clinic her facial 347-352 q Fall 1997 AAO Journal/29.