Facial+Paralysis+(Bell's+Palsy)

Bell's palsy is a form of temporary facial paralysis resulting from damage or trauma to the seventh cranial nerve, one of the two facial nerves. The paralysis causes distortion of facial features and interferes with normal facial function.

The onset of Bell's palsy usually is sudden. Many people wake up in the morning and find that one side of their face is paralyzed. Patients often fear that they have suffered a stroke, but Bell's palsy is not related to stroke. It does however correlate to the Chinese disease category of "wind stroke".

Incidence and Prevalence
Bell's palsy affects about 40,000 people in the United States every year. It affects approximately 1 person in 65 during a lifetime. Bell's palsy is more commonly seen in young adults, and persons of Japanese descent have a slightly higher incidence of the condition. Bell's palsy is the most common cause of facial paralysis worldwide and one of the most common neurological disorders involving a cranial nerve. Incidence of Bell's palsy in males and females, as well as in various races, is approximately the same.

Etiology
Classically, Bell’s palsy has been defined as idiopathic, and the cause of the inflammatory process in the facial nerve remains uncertain. Recently, attention has focused on infection with herpes simplex virus type 1 (HSV-1) as a possible cause, though this is by no means certain.

Signs and Symptoms
-Unilateral facial weakness or paralysis -Inability to blink or close the eye, frown, raise the eyebrow, puff out the cheek, whistle, or show the teeth -Tearing and dry eyes -Dry mouth
 * The most common symptoms of Bell's palsy are :**

-Impaired speaking -Drooling -Difficulty eating -Facial twitching -Impaired sense of taste (hypogeusia or ageusia) -Hypersensitivity to sound -Dizziness
 * Other symptoms include the following:**

The severity of symptoms depends on the extent of facial nerve damage and varies from mild weakness to complete paralysis. Bell's palsy usually affects both the upper and lower parts on one side of the face. Both sides of the face are affected in less than 1% of cases. Symptoms usually come on suddenly and progress quickly, reaching maximum severity in 48 hours or less. Several hours before the onset of facial weakness, many people experience pain behind the ear or in the back of the head. //In about 60% of cases, patients are recovering from a recent upper respiratory infection or other viral infection.// Bell's palsy is self-limiting. Symptoms do not spread beyond the face and do not worsen once they "peak.“

Diagnosis and Differential
-Ask the patient to raise her eyebrows. Assess whether the wrinkles on the forehead have become shallower or disappeared. -Ask the patient to close her eyes while you attempt to open them. This helps you gauge the strength of the orbicularis oculi muscle. -Visually examine the nasolabial and mentolabial folds on the affected side to determine whether they have become shallower or disappeared altogether. -Ask the patient to a) purse her lips, b) puff up her cheeks and blow out, and c) then smile widely and show her teeth. If the patient is unable to perform a & b and if the number of teeth revealed on one side is less than the other, the results are positive for a dysfunction of the orbicularis oris muscle. Check whether there is tenderness on or below the mastoid process. -If all tests are positive than the diagnosis is peripheral facial paralysis, Bell’s palsy, though in some cases the mastoid process may not be tender on palpation. If only the third and fourth tests are positive, then the facial paralysis is a result of central nervous dysfunction.

A patient with an acute onset of unilateral facial weakness most likely has Bell’s palsy. A careful history of the onset and progress of paralysis is important because gradual onset of more than two weeks’ duration is strongly suggestive of a mass lesion. Medical history should include recent rashes, arthralgias, or fevers; history of peripheral nerve palsy; exposure to influenza vaccine or new medications; and exposure to ticks or areas where Lyme disease is endemic. Conditions that can produce isolated facial nerve palsy identical to Bell’s palsy: -Structural lesions in the ear or parotid gland (e.g., cholesteatoma, salivary tumors)

Other causes of peripheral nerve palsies usually have additional features that distinguish them from Bell’s palsy: -Guillain-Barré syndrome, Lyme disease, Otitis media, Ramsay Hunt syndrome (an outbreak of herpes zoster in the facial nerve distribution), Sarcoidosis, Some influenza vaccines

Biomedical Treatment
-Recommended treatment: a seven-day course of acyclovir or valacyclovir and a tapering course of prednisone, initiated within three days of the onset of symptoms is believed to reduce the time to full recovery and increase the likelihood of complete recuperation. -Eye lubricants for eye irritation -Analgesics such as aspirin, acetaminophen, or ibuprofen to relieve pain -Decompression surgery for Bell's palsy -- to relieve pressure on the nerve -- is controversial and is seldom recommended.

Prognosis
The prognosis for individuals with Bell's palsy is generally very good. The extent of nerve damage determines the rate and extent of recovery. -Between //60% and 80% of patients experience complete recovery// within 3-6 months, whether or not they receive treatment. -Others are left with varying degrees of facial disfigurement, paralysis, or muscle spasms. -Approximately 7–10% of patients experience a recurrence.

TCM Disease Categorization
Kōu Yān Wāi (Kuāi) Xié: “deviated eyes and mouth;” “facial paralysis”

TCM Etiology and Pathogenesis
Exogenous pathogenic factors: Wind-Cold (or Wind-Heat) invade the Yang channels and collaterals of the face obstructing the flow of Qi and Blood. Wind in the channels can also stir up latent Phlegm, which can further obstruct Qi and Blood. Lack of nourishment from Qi stagnation and Blood stasis due to Wind invasion causes facial paralysis. Underlying Qi and Blood vacuity (due to illness or poor diet) allows for invasion of exogenous pathogenic factors.

Facial Paralysis
Includes the loss of motor & sensory coordination of facial muscles, inability to properly open & close the affected eye, inability to control the movement of the affected side of the mouth, and drooling Strengthen the effect of extinguishing wind: + Tian Ma, Gou Teng, Shi Jue Ming To dispel Wind: + Jing Jie (10g), Fang Feng (10g), Bai Zhi (10g), Ju Hua (12g), Man Jing Zi (10g) For Blood stasis: + Hong Hua (10g) Strengthen the effect of relaxing the sinews & unblocking the channels: + Bai Shao, Mu Gua If Underlying Qi and Blood Vacuity Is Significant (Usually after symptoms are resolved): Ba Zhen Tang
 * Treatment Strategy:** Dispel wind, resolve phlegm & unblock the channels
 * Herbal Treatment:** Qian Zheng San
 * Modifications:**

**Acupuncture Treatment**
(with the exception of LI-4, needle on affected side only) Inability to furrow: BL-2, GB-1, TW-23, Yu Yao Shallow nasolabial groove: LI-20, Bi Tong Pain at corner of jaw, mastoid process, or pain in the ear: TB17 Deviation of philtrum: GV-26 Deviation of mentolabial sulcus: CV-24, Jia Cheng Jiang Hypogeusia or ageusia: CV-23 Incomplete closing of the eye: + BL-2, BL-1, GB-1, Yu Yao, TW-23\ Difficulty in sniffing: + LI-20 Inability to show the teeth: + ST-3 Tinnitus & deafness: + GB-2 Tenderness in the mastoid region: + GB-12, TW-5 Long standing cases: + Tai yang, St-6, ST-4, ST-3, ST-7 (use warm-needle or moxa on all) Wind-Cold: GV-14 Wind-Heat: SJ-5, LI-11, GV-14 Wind-Phlegm: ST-36, ST-40 Qi and Blood deficiency: ST-36, SP-6,CV-6, BL-17
 * Basic points:** ST-2, ST-4, ST-6, BL-2, Yu Yao, Qian Zheng, TB-23, GB-1, GB-14, GB-20, LV-3, LI-4
 * Modification based on the symptoms:**
 * Modification based on the syndromes:**

The more frequent the treatments, the more quickly the patient will respond and the more likely recovery will be complete. Every day or every other day is ideal, at least in the first couple weeks. In the beginning, do not use strong stimulation.

-Cupping -Electroacupuncture: ordinarily reserved until after the first or second week of treatment. -Indirect moxa.
 * Other Modality Options**

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 * IBIS:**

Definition:
The sudden occurrence of unilateral paralysis of the facial nerve (cranial nerve VII). It is the most common form of facial paralysis (around 1 in every 60-70 persons in a lifetime)

Etiology:
The cause of the disease is unknown. The pathology involves swelling of the seventh nerve from viral or immune disease, leading to ischemia and compression of the nerve where it traverses through the narrow area of the temporal bone. The scattered cases that have been autopsied showed nondescript differences in the normal appearance of the nerve and no inflammatory changes.

Somatic therapies:
• mirror exercises: 3 to 4 times per day - continue 1 month or until full recovery • recite vowels slowly and distinctly with precise lip movements 3-4 times daily

Nutrition:
therapeutic foods: • foods that rid Wind, open channels, and clear Obstructions • foods rich in Vitamin B-complex and Vitamin C • increase foods rich in Calcium, Phosphorus, Manganese, Sulfur, Iodine, tryptophan (Jensen, p. 63) • egg yolk, kale, celery, fish, raw goat's milk, veal joint broth, cod roe, rice polishings, brewer's yeast, nutritional yeast (Jensen, p. 63)

fresh juices: • celery, carrot, prune (Jensen, p. 63) • prune and rice polishings (Jensen, p. 63) • raw goat's milk and 1 tsp. sesame, sunflower, or almond butter, 1 tsp. honey and sliver of avocado (Jensen, p. 63) • black cherry and egg yolk (Jensen, p. 63)

specific remedies: • grind castor beans without shells to make a cream, and apply externally to the affected side of the mandibular joint and angle of mouth, then cover with a bandage, changing dressing once every day. Continue 3-4 days (Lu, p. 107)

Botanicals
• Avena sativa: nerve tonic (Felter and Lloyd, p. 316) • Hypericum perforatum: neural injuries (NCNM Botanicals) • Strychnos nux vomica (toxic): externally (Burke) • Viburnum prunifolium: palsy for women (Harper-Shove, p. 186) • Strychnos nux vomica: use tincture to make ointment, apply locally (Bensky and Gamble)

Chinese Formulae
• Da Huo Luo Dan (patent): Xue Yu (Blood Stasis) with Qi Stagnation: flaccid paralysis (Zhu, p. 139) • Ginseng and Astragalus C. (Bu Zhong Yi Qi Wan) (available as patent): chronic drooping of upper eyelids (Hsu, 1980, p. 255; Yeung, p. 51; Dharmananda, 1986, p. 186; Bensky and Barolet, p. 241; patent: Zhu, p. 270) • Tian Ma Wan (patent): Acute: use as soon as possible after onset (Naeser, p. 136) • Tsai Tsao Wan (patent): Wind-Damp (Fratkin, p. 139) • Gastrodia 9 (patent) plus Morus Fruit Tablets (patent): Xue Xu (Blood Deficiency) with Liver Wind Generated by Extreme Heat (Dharmananda, 1990; Gastrodia, p. 83; Morus Fruit Tablets, p. 86) • Yan Shen Jai Jao Wan (patent): Wind-Damp (Fratkin, p. 140)

Acupuncture
after assessing the person and palpating, consider these patterns: Wind-Cold; Phlegm

» illustrative combinations: • qian zheng, St-4, GB-20 and GB-14 for facial paralysis (Shanghai, p. 156) • GB-14, St-2, qian zheng and St-4 or joined to UB-2 or TW-23, for facial paralysis (Shanghai, p. 146) • LI-19, qian zheng, CV-24 and GB-20 for facial paralysis (Shanghai, p. 158) • 1st (+) LI-4 and Lv-3, then St-4 and St-6 on unaffected side; next moxa (D) same; then (+) St-4 and St-6 affected side (McWilliams, et al., Lesson 31, p. 31) • UB-2, TW-23, St-4 and St-4 for facial paralysis (Shanghai, p. 148); • St-2, UB-2, GB-20 and LI-4 for facial paralysis (Shanghai, p. 152); • St-2, qian zheng, St-4, LI-19 and GB-14 for facial paralysis (Shanghai, p. 154); • St-2, St-4, LI-4, GB-14 and GB-20 for facial paralysis (Shanghai, p. 609) • LI-4, GB-14, UB-2, UB-1, TW-23, St-1, LI-20, SI-18, qian zheng, St-4 and St-6 for facial paralysis due to Wind-Cold causing Stagnation of Qi and Xue (Blood) (Jirui and Wang, p. 118) • Lu-7, Kd-6, SI-3, UB-62, GB-20, SI-18, GV-26, CV-24, St-6, St-4, GB-14 and UB-2 for acute facial paralysis due to Wind-Cold (Jirui and Wang, p. 120) • St-6 -> St-4, St-2 and LI-4 (-): spread Qi through face; local points to dispel Wind • GV-20, GB-14, St-4, St-2, LI-4 (also consider GV-26, jia cheng jiang, tai yang, St-7, St-36, St-44, LI-19 for facial paralysis (Lee and Cheung, p. 300) • TW-17, SI-17, GB-2, St-3, St-2, UB-2, TW-23, GB-7, St-6, GB-1, St-4, LI-19 for facial paralysis (Lee and Cheung, p. 300) • St-6, GV-26, Lu-7, Lu-9, LI-4, LI-2, St-4 and TW-23 for facial paralysis of mouth and eye (Lee and Cheung, p. 300) • LI-7, LI-6, LI-2 and St-44 for paralysis of mouth (Lee and Cheung, p. 300) • tai yang, UB-2, St-2, St-7 and jia cheng jiang (also consider LI-4, St-44, Lv-3, St-36, TW-5, Kd-3 and GB-20) for trigeminal neuralgia (Lee and Cheung, p. 320) • LI-3 and LI-4; add tai yang, GB-3, GB-14 and UB-2 for 1st branch; add GB-1, St-2, St-7, SI-18 and St-3 for second branch; add St-6, St-5 and GB-2 for third branch of trigeminal neuralgia (Lee and Cheung, p. 321) • GB-1, LI-4 and tai yang (also consider yin tang) for trigeminal neuralgia (Lee and Cheung, p. 321) • UB-7 and UB-6 for mouth awry, watery nasal discharge (Shanghai, p. 143)

Homeopathy
• Aconitum napellus: gnawing and evading pain and sensation in cheeks; distortion of features; tense drawing in trigeminal nerve; pain followed by drawing in jaws; sudden onset of symptoms • Ammonium phosphoricum: facial paralysis; chronic gouty patients with nodosities of joints of the fingers • Causticum: paralysis of right side; pain in facial bones, in jaw; difficulty opening mouth; after typhus; gradual; exposure to cold air; mouth draws to one side • Derleamosa: paralysis of lower jaw; twitching of lips in cold air; mouth drawn to one side with tenacious salivation; paralysis of tongue and difficulty talking especially after taking cold; < from cold and damp; from sleeping on damp ground • Gelsemium: paralysis of upper lips after prolonged conversation; muscles contracted; neuralgia in distinct paroxysms with contraction and twitching; jaws locked; lower jaw dropped; chin quivers incessantly; no control over lower jaw; functional paralysis • Graphites: semi-lateral paralysis; distortion of facial muscles; difficult articulation, speech impeded • Kali chloricum: jerking of lower jaw; lightning-like neuralgic pains; < talking, eating, slightest touch; cramp-like pain in joint of jaw with stitches in jaws and teeth • Kali iodum: malar bones sensitive to touch; cannot move cheeks and lips; tearing pains in joints of jaw • Rhus toxicodendron: face disfigured and convulsed; face burning with red heat; cramp-like jaw pain > strong external pressure and warmth; spasms in jaw; constant desire to yawn • Senega: sensation as if left half of face paralyzed; digging in teeth on inspiration • Zincum metallicum: facial paralysis; brain fag; loss of memory and energy; cramp-like tearing, especially chin; after herpes zoster; fidgety feet, has to move them constantly

Subtle Support
• Ti (Gardner, p. 117)

pain: • Mendelssohn's Spring Song • Meditation from Thais • Chopin's Preludes • On Wings of Song • Andante, Beethoven's Fifth Symphony • Adagio, Beethoven's Pathetique Symphony (Heline, p. 18)

musculoskeletal: • Sousa's marches • The Anvil Chorus • William Tell Overture • Brahm's Hungarian Dances • By the Waters of the Minnetonka (Heline, p. 18)

Mind/Body
• Extreme control over anger; unwillingness to express feelings. (Hay, 1988, p. 17)

Chinese psychophysiology: • Typically considered a form of Wind, of either an internal or external origin, that most commonly appears along the course of the Stomach channel on the face.

• Stomach ~ Wei is the Sea of Nourishment and origin of all fluids; with the Spleen, is the root of post-natal Qi; and as Earth, relates to the ability to assimilate, stabilize, and feel balanced and centered. » Mental signs of Stomach channel disorders include depression, death wishes, instability, suicidal tendencies, mentally overwrought, doubt, suspicions, tendency to mania, and slowness at assimilating ideas. (Seem, p. 27)

• Liver ~ Gan is the home of the Hun (Ethereal Soul); it relates to decisiveness, control, and the principle of emergence; maintains smooth flow of Qi; reflects emotional harmony and movement; and expresses itself in the nervous system. » Healthy expressions are kindness, spontaneity, and ease of movement. » Liver Qi Stagnation reflects and accentuates emotional constraint as the Liver's function of facilitating smooth flow in the body is constricted. Stagnation is associated with frustration, irritability, tension, and feeling stuck. With time this pattern tends to produce a gloomy emotional state of constant resentment, repressed anger or depression, along with tightness in the chest, frequent sighing, abdominal tension or distension, and/or a feeling of a lump in the throat with difficulty in swallowing. (Maciocia, p. 216) » Liver Wind derives from Liver Yin Xu (Deficiency) and/or Liver Xue Xu (Blood Deficiency) and their subsequent inability to embrace the Yang, and can manifest as joint stiffness, dizziness, tremor, paralysis, convulsions, rashes, itching, and neurological problems. Wind can also be internalized after exposure to inclement, especially windy, weather and any concomitant influences of Damp, Cold, and/or Heat. » Liver Shi (Excess) signs include discontent; anger; pain in lumbar region and genitals (Seem, p. 28); muscular tension; excessive sex drive; insomnia; moodiness; excitability; genital diseases; red, tearing eyes; compulsive energy; and bitter taste in the mouth. Chronically suppressed anger can implode and give rise to Fire in the Liver and Gall Bladder with symptoms of irritability, bitter taste, headaches, etc.