Bell's Palsy

What is Bell's palsy?

Bell's palsy is an unexplained episode of facial muscle weakness or paralysis that begins suddenly and worsens over three to five days. This condition results from damage to the 7th (facial) cranial nerve, and pain and discomfort usually occurs on one side of the face or head.

It can strike anyone at any age, but it occurs most often in pregnant women, and people who have diabetes, influenza, a cold or another upper respiratory ailment. According to the National Institute of Neurological Disorders and Stroke, this nerve disorder affects about 40,000 U.S. adults and children each year. Bell's palsy strikes men and woman equally. It is less common before age 15 or after age 60.

Bell's palsy is not considered permanent, but in rare cases it does not disappear. Currently, there is no known cure for Bell's palsy; however, recovery usually begins two weeks to six months from the onset of the symptoms. The majority of people with Bell's palsy recover full facial strength and expression.

What causes Bell's palsy?

A specific cause of Bell's palsy is unknown, however, it has been suggested that the disorder is due to inflammation that is directed by the body's immune system against the nerve controlling movement of the face. The weakness or symptoms seen in Bell's palsy is sometimes associated with the following:

• Diabetes

• High blood pressure

• Trauma

• Toxins

• Lyme disease

• Guillain-Barré syndrome

• Sarcoidosis

• Myasthenia gravis

• Infection, especially following a viral infection with Herpes simplex virus (a virus that is related to the cause of the common "cold sores" of the mouth)

These conditions cause weakness through a different mechanism than the usual inflammation of Bell's palsy.

What are the symptoms of Bell's palsy?

The following are the most common symptoms of Bell's palsy. However, each individual may experience symptoms differently. Symptoms may include:

• Disordered movement of the muscles that control facial expressions, such as smiling, squinting, blinking, or closing the eyelid

• Loss of feeling in the face

• Headache

• Tearing

• Drooling

• Loss of the sense of taste on the front two-thirds of the tongue

• Hypersensitivity to sound in the affected ear

• Inability to close the eye on the affected side of the face

  
  

Facial Reconstruction and Injuries

Facial reconstruction

Facial reconstruction, which is a subspecialty of craniofacial surgery, is surgery that rebuilds any part of the face, including bones and soft tissue. Injury, trauma and cancer are most often the cause for needing facial reconstruction surgery. Other patients come to plastic surgeons when a tumor, mole or other growth has been removed from the face; for growth or development problems; and for vascular or lymph malformations.

Using techniques employed in cosmetic and microvascular reconstructive surgery, like fat and skin grafting and bone and soft tissue transplantation, the surgeons can often replace missing or disfigured parts of the face with tissue and bone from nearby areas. For example, neck skin and fat can be moved up to the cheek to replace the skin and tissue there. Tissue can be removed from another part of the body (such as the abdomen or leg), moved to the face, and covered with skin from a nearby area.

Paralysis and pain

Facial paralysis and pain can be debilitating and cause those suffering from the conditions to retreat from the activities of daily living. Facial paralysis can be caused by a number of conditions, including:

• Traumatic injury
• tumor removal
• Surgery
• Stroke
• Infection
• Bells Palsy
• Moebius syndrome, a birth defect that results in the absence of the sixth and seventh facial cranial nerve
• Other congenital abnormalities

Facial pain generally stems from:

• Trigeminal Neuroma
• Trigeminal Neuragia
• Atypical Facial Pain

Pediatric Reconstruction

Depending on the condition, the child may be able to have surgery within his or her first year of life. In some cases, it may be better to wait longer. And in other cases, a series of surgeries may be needed. 

Craniofacial Conditions and Syndromes

Craniofacial microsomia, sometimes known as hemifacial microsomia or otomandibular dysostosis, among other names, is a condition that causes children to be born with underdeveloped or small parts of the face, most commonly the jaw and ear (which may be called microtia). After cleft lips and palates, this is the most common facial birth defect.
Some children are born with Pierre Robin Sequence, which may also be called Pierre Robin Syndrome or Pierre Robin Malformation. It is characterized by a jaw that is too small, a cleft palate, retraction of the tongue and upper airway obstruction. As with other types of facial conditions, the jaw and cleft palate can be repaired with surgery.

Obstetric brachial plexus injury

In infants, brachial plexus injury most often occurs during an abnormal or difficult birth, causing damage to the brachial plexus nerves (shoulder dystosia). Depending on the injury, a baby may be diagnosed with different kinds of palsy, including Erb’s palsy and Klumpke’s palsy. In about one in 10 cases, the child will need some kind of surgery to repair the nerves. Generally, surgeons recommend that the surgery be done when children are between the ages of four and nine months.
Jaw surgeries: For a child born with a small jaw or receding chin, a reconstructive surgeon can correct the condition through several different kinds of surgery. Most commonly, the reconstructive surgeon will cut the jawbone, a procedure known as an osteotomy, to reposition it using titanium screws and plates, which eliminates the need for wiring the teeth together.
Another technique, distraction osteogenesis, splits the jawbone and then moves the jawbone slowly by inserting a screw either inside the mouth or outside and turning it periodically over a few weeks. The advantage of the distraction technique is that it simultaneously increases bone length and the volume of the soft tissue around the bones.
The plastic surgeon may also create a new jawbone structure using bone grafts from the ribs, hips, or skull, or alloplastic grafts, which are created from synthetic materials.
Ear surgeries: Reconstructing the ear to make it a normal size will likely require three surgeries over a period of time. In some cases, a child may need an artificial or prosthetic ear, which also requires several surgeries.
Repairing the ear can take anywhere from two to four surgeries. The reconstructive surgeon may recommend using the child’s ribs to reconstruct the ear or may decide that an alloplast—synthetic material—would be best.

Jaw Synthesized Information

Problems with the jaw can result in difficulty speaking, eating, swallowing, breathing, and sleeping. Some people may have a facial disfigurement—a severely receding chin or protruding jaw or an unbalanced appearance from the front or side. In some cases, jaw problems can be the source of other health problems, such as debilitating headaches or sleep apnea. A severe overbite or underbite may make it impossible to close the teeth or lips together.

The most common jaw problem in children is cleft lip and palate.

Correcting jaw problems

A reconstructive surgeon can correct jaw conditions and injuries through surgery that repositions the jaw. This is sometimes called a maxillofacial procedure. Most commonly, the reconstructive surgeon will cut the jawbone, a procedure known as an osteotomy, to reposition it using titanium screws and plates. This eliminates the need for wiring the teeth together.

Another technique, distraction osteogenesis, splits the jawbone and then moves the jawbone slowly by inserting a screw either inside the mouth or outside and turning it periodically over a few weeks. The advantage of the distraction technique is that it simultaneously increases bone length and the volume of the soft tissue around the bones.

The plastic surgeon may also use bone grafts, taking bone from ribs, hips, or skull, or alloplastic grafts, created from synthetic materials, to create a new jawbone structure.

Reconstructive jaw surgery is major surgery that will require general anesthesia and a hospital stay of a few days as well as recovery time at home afterward.

Complete Information Synthesized (Summary Part III)

Hand Injuries and Conditions

Hand injuries and conditions—from injuries to carpal tunnel syndrome to rheumatoid arthritis—can be mildly irritating or severely debilitating. Whether mild or severe, they often inhibit a person’s ability to live his or her life fully. In some cases, a person may not be able to work, play with children or grandchildren, enjoy recreational activities, or get dressed or do other types of daily living activities.

When the injury or condition becomes severe, surgery may be the solution that can best restore function to the affected area and alleviate pain. A hand surgeon operates on the hand and the lower arm up to the elbow. Many conditions and injuries may call for hand surgery, including:

• Abnormally shaped fingers or hands
• Amputations
• Arthritis
• Carpal tunnel syndrome
• Ganglion cysts
• DeQuervain’s disease
• Dupuytren’s contracture
• Flexor tendon injuries
• Fractures
• Lacerations
• Mallet finger
• Missing fingers, thumb
• Nailbed injuries
• Polydactyly (extra fingers)
• Reflex sympathetic dystrophy
• Syndactyly (webbed fingers)
• Tendonitis
• Trigger finger
• Ulnar nerve compression
• Vascular disorders

Most Common Hand Conditions

Carpal Tunnel Syndrome

The most common condition requiring surgical intervention is carpal tunnel syndrome, which is caused by pressure on the median nerve in the wrist. Symptoms may include tingling, pain, numbness, or weakness in the thumb through ring fingers of the affected hand. Nerve compression can be caused by a number of things, including repetitive motions, injury, cysts, and tumors. For many patients, there may not be an identifiable source of the nerve compression. To relieve the symptoms of carpal tunnel syndrome or other nerve compression conditions through surgery, the reconstructive surgeon makes an incision in the elbow or wrist and relieves the compression, either by giving the nerve more room, removing a cyst or tumor, or moving the nerve. Read more about carpal tunnel syndrome in Johns Hopkins Health, our community newsletter about the latest advances in medicine.

Arthritis

When the normally smooth surfaces of a joint become irregular and don’t glide well anymore, the joint wears out, resulting in arthritis—or painful joints. Several kinds of surgery can relieve the inflammation and pain caused by arthritis and, in some cases, can also restore mobility.

With joint fusion surgery, the reconstructive surgeon will remove the arthritic surface and fuse the bones on each side of the joint together. While this type of surgery keeps the joint from moving, it does relieve pain and correct deformities that may interfere with daily living activities. Read more about joint reconstruction surgery in Cutting Edge, a Department of Surgery publication. 

Joint reconstruction surgery replaces the arthritic surface with soft tissue, like a tendon, or a joint replacement implant. This surgery can relieve the pain of arthritis while preserving mobility of the joint. The reconstructive surgeon consults with the patient and other doctors to determine what type of surgery would be the best solution for the patient’s needs.

Complete Information Synthesized (Summary Part II)

Body Injuries and Conditions

Brachial plexus injuries

The brachial plexus is a network of nerves that sends signals from the spinal cord to the shoulder, arm and hand. When those nerves are damaged, it is considered a brachial plexus injury. Injury can occur during birth, from tumors putting pressure on nerves, trauma (such as an accident), or inflammation. If you have a brachial plexus injury, you may experience pain or numbness, an inability to move your arm or hand, or a feeling of limpness.

Obstetric brachial plexus injury: In infants, brachial plexus injury most often occurs during an abnormal or difficult birth, causing damage to the brachial plexus nerves (shoulder dystosia). You can find out more about brachial plexus injuries on our Pediatric Injuries and Conditions page. 

Lymphedema

Lymphedema is caused by the buildup of lymph fluid, which causes nearby body parts, such as the arm or leg, to swell. This condition most often occurs due to injury, when lymph nodes are removed or become scarred, or if there is trauma to the lymphatic system. For example, some women who have undergone treatment for breast cancer develop lymphedema after the treatment.

While older surgical techniques have not successfully cured lymphedema, Johns Hopkins reconstructive surgeons have experience in new techniques that show promise in effectively treating it. In vascularized lymph node transfer, or lymphovenous bypass, the reconstructive surgeon moves lymph nodes from the groin area to the armpit and reconnects them to blood vessels. The new lymph nodes remove the excess fluid returning it to the lymphatic system. In lymphaticovenous anastomosis, the reconstructive surgeon uses microsurgery to join lymphatic channels in the affected area to nearby veins.

This surgical treatment of lymphedema is not a cure-all, according to plastic and reconstructive surgeon Justin Sacks, but it has a low risk of complications and may alleviate discomfort for some.

Peripheral nerves are those located outside of your brain and spinal cord. When there is something wrong with peripheral nerves in some part of the body, it interrupts the signals between the spinal cord and brain and that part of the body. There are more than 100 kinds of peripheral nerve disorders.

One of the most common and well-known peripheral nerve disorders is carpal tunnel syndrome, which is caused by nerve compression on the median nerve in the wrist and often occurs in people who do repetitive motions involving their wrists and hands. If you have carpal tunnel syndrome, your symptoms may include pain, weakness, numbness, or tingling in your hand or wrist, or up your arm. Other types of peripheral nerve injuries may stem from illnesses like viral infections and diabetes. In other cases, people are born with peripheral nerve disorders.

The decision to repair a peripheral nerve disorder through surgery is one that may be quite complex, depending on the type of problem, the severity of the pain, the severity of neurological symptoms associated with the problem, and how well other kinds of treatment have worked.

Complete Information Synthesized (Summary)

Maxillofacial injuries are commonly encountered in the practice of emergency medicine. More than 50% of patients with these injuries have multisystem trauma that requires coordinated management between emergency physicians and surgical specialists in oral and maxillofacial surgery, otolaryngology, plastic surgery, ophthalmology, and trauma surgery.

Trauma to the maxillofacial anatomy mandates special attention. Contained within the face are systems that control specialized functions including seeing, hearing, smelling, breathing, eating, and talking. Also, the vital structures in the head and neck region are intimately associated. Lastly, the psychological impact of disfigurement can be devastating.

The maxillofacial region is divided into 3 parts.

• The upper face: Here, fractures involve the frontal bone and frontal sinus.
• The midface: The midface is divided into upper and lower parts. The upper midface is made up by the zygoma, nasal bones, ethmoid bone, and non-tooth–bearing segment of the maxillary bone. This is where maxillary LeFort II and LeFort III fractures occur and/or where fractures of the nasal bones, nasoethmoidal complex (NOE) or zygomaticomaxillary complex (ZMC), and the orbital floor occur. The lower midface is composed of the maxillary alveolus, teeth, and the palate and is where LeFort I fractures occur.
• The lower face: This is composed of the mandible, where fractures can occur

More than 3 million facial injuries occur in the United States each year. Most are secondary to assaults and motor vehicle accidents. Information about the causes of facial fractures depends on the country and location of the trauma center; therefore, reported statistics vary widely.

Etiology of MI

Facial trauma in an urban setting is most often caused by assaults, followed by motor vehicle and industrial accidents.

The nasal bones, mandible, and the zygoma are the most commonly fractured bones during assaults. Facial trauma in the community setting is most often due to motor vehicle accidents, followed by assaults and recreational activities. Motor vehicle accidents produce fractures that often involve the midface, especially in patients who were not wearing their seatbelts. Other important causes of facial trauma include penetrating trauma (knife and gunshot wounds), domestic violence, and the abuse of children and elderly persons.

Pathophysiology 

The kinetic energy present in a moving object is a function of the mass multiplied by the square of its velocity. The dispersion of this kinetic energy during deceleration produces the force that results in injury. High-impact and low-impact forces are defined as greater or lesser than 50 times the force of gravity. These parameters impact on the resultant injury because the amount of force required to cause damage to facial bones differs regionally. The supraorbital rim, the maxilla and the mandible (symphysis and angle), and frontal bones require a high-impact force to be damaged. A low-impact force is all that is required to damage the zygoma and nasal bone.

• Frontal bone fractures: These result from a severe blow to the forehead. The anterior and/or posterior table of the frontal sinus may be involved. Assume a dural tear is present if the posterior wall of the frontal sinus is fractured. The nasofrontal duct often is disrupted.
• Orbital floor fractures: Injury to the orbital floor can result in an isolated fracture or can be accompanied by a medial wall fracture. When a force strikes the globe or orbital rim, the intraorbital pressure increases with transmission of this force and damages the weakest aspects of the orbit, the floor and medial wall. Herniation of the orbital contents into the maxillary sinus is possible. The incidence of ocular injury is high, but globe rupture is rare.
• Nasal fractures: These are the result of the forces transmitted during direct trauma.
• Nasoethmoidal fractures (NOE): These extend from the nose to the ethmoid bones and can result in damage to the medial canthus, lacrimal apparatus, or nasofrontal duct. They also can result in a dural tear at the cribriform plate.
• Zygomatic arch fractures: A direct blow to the zygomatic arch can result in an isolated fracture involving the zygomaticotemporal suture.
• Zygomaticomaxillary complex fractures (ZMC): These fractures result from direct trauma. Fracture lines extend through zygomaticotemporal, zygomaticofrontal, and zygomaticomaxillary sutures and the articulation with the greater wing of the sphenoid bone. The fracture lines usually extend through the infraorbital foramen and orbital floor. Concurrent ocular injuries are common.
• Maxillary fractures: These are classified as Le Fort I, II, or III
  

  • LeFort I fracture is a horizontal maxillary fracture across the inferior aspect of the maxilla and separates the alveolar process containing the maxillary teeth and hard palate from the rest of the maxilla. The fracture extends through the lower third of the septum and includes the medial and lateral maxillary sinus walls extending into the palatine bones and pterygoid plates.
  • LeFort II fracture is a pyramidal fracture starting at the nasal bone and extending through the ethmoid and lacrimal bones; downward through the zygomaticomaxillary suture; continuing posteriorly and laterally through the maxilla, below the zygoma; and into the pterygoid plates.
  • LeFort III fracture or craniofacial dysjunction is a separation of all of the facial bones from the cranial base with simultaneous fracture of the zygoma, maxilla, and nasal bones. The fracture line extends posterolaterally through ethmoid bones, orbits, and pterygomaxillary suture into the sphenopalatine fossa. See the image below.
    
• Mandibular fractures: These can occur in multiple locations secondary to the U-shape of the jaw and the weak condylar neck. Fractures often occur bilaterally at sites apart from the site of direct trauma.
• Alveolar fractures: These can occur in isolation from a direct low-energy force or can result from extension of the fracture line through the alveolar portion of the maxilla or mandible.
• Panfacial fractures: These usually are secondary to a high-energy mechanism resulting in injury to the upper face, midface, and lower face. These fractures must be composed of at least 3 of the possible 4 facial units in order to be labeled panfacial. See the image below.