BELL’S PALSY

Identitas Pasien
• Nama : An. AW
• Jenis Kelamin : Perempuan
• Umur : 15 tahun
• Alamat : Gowa
• Pekerjaan : Pelajar SMA
• Tanggal Kasus : 8 Januari 2019
• MR : 038948
• Perawatan : Poli Saraf
Riwayat Penyakit
• Seorang remaja perempuan, umur 15 tahun datang ke poli
Saraf RS Sayang Rakyat dengan keluhan mulut mencong
ke kanan yang dialami sejak 3 hari yang lalu. Awalnya
mengeluh rasa sakit di leher bawah telinga kiri saat
bangun pagi 3 hari lalu, kemudian mata kiri mulai sulit
berkedip dan terus mengeluarkan air mata. Besoknya
pasien mulai kesulitan minum dan mengunyah saat
makan. Riwayat terpapar dingin 4 hari lalu (+), pasien
mengendarai motor dan kehujanan di malam hari sebelum
gejala muncul. Demam (-), nyeri kepala (-), pusing berputar
(-), mual (-), muntah (-), kesulitan menelan (-). BAB: biasa,
BAK: lancar
Riwayat Penyakit
• Riwayat pengobatan : Pasien mengaku belum pernah
berobat dan sedang tidak mengkonsumsi obat apapun.
• Riwayat penyakit sebelumnya: Riwayat penyakit hipertensi
tidak ada. Riwayat Dyspepsia ada.
Pemeriksaan Fisik
Status Internus:
Keadaan Umum: Sakit Sedang/Gizi Cukup/Compos Mentis
Tanda Vital:
• - Tekanan Darah : 100/70 mmHg
• - Nadi : 72x/menit
• - Pernapasan : 18x/menit
• - Suhu : 36,6º
Kepala:
• - Ekspresi wajah : kesan wajah lumpuh sebelah kiri
• - Rambut : hitam
• - Bentuk : normocephali
Mata:
• - Konjungtiva : pucat (-/-)
• - Sklera : ikterik (-/-)
• - Eksophtalmus (-), Nystagmus (-), Lagophtalmus ( - / + )
Mulut: bibir sianosis (-), luka, kesan sulcus nasolabialis menghilang
Status Neurologis
• GCS: E4M6V5
• FKL: dalam batas normal
• RM: Kaku kuduk (-), Kernig sign (-)
• Nn. Cranialis: pupil isokor, diameter 2.5mm, RCL +/+, RCTL +/+
• Nn. Cranialis lain: parese N.VII sinistra tipe perifer
• Motorik:

• Sensibilitas : dalam batas normal

• SSO: BAB biasa, BAK lancar
DIAGNOSIS DAN TERAPI
Diagnosis
• Diagnosis klinis : Paralisis N.VII perifer sinistra
• Diagnosis etiologi : idiopatik
• Diagnosis topis : N.VII perifer dibawah foramen
stylomastoideus
TERAPI
Farmakoterapi:
• Prednison 5 mg 3 x 4 tablet selama 5 hari (Tapering off)
diturunkan perlahan
• Ranitidin 150 mg 2x1
• Mecobalamin 2x1
• Asiclovir 400 mg 5x1
Non-Farmakoterapi:
• Edukasi kepada pasien dan keluarga tentang penyakit dan
pengobatan yang diberikan.
• Kompres air hangat pada bagian yang sakit +/- 20 menit
• Massage wajah kearah atas.
• Fisioterapi
BELL’S PALSY
Definisi
• Bell’s palsy merupakan salah satu gangguan neurologik
yang paling sering mempengaruhi nervus cranialis.
Gangguan ini berupa paresis atau paralisis fasial perifer
yang terjadi tiba-tiba, bersifat unilateral tanpa penyebab
yang jelas.
• Additional symptoms may include pain in or behind the ear,
numbness in the affected side of the face, hyperacusis,
and disturbed taste on the ipsilateral anterior part of the
tongue.2-5
Incidence and Prevalence
• The incidence is around 23 per 100,000 people per year,
or about 1 in 60 to 70 people in a lifetime. It affects men
and women more or less equally, with a peak incidence
between the ages of 10 and 40. It occurs with equal
frequency on the right and left sides of the face.
Etiologi
• Diperkirakan, penyebab Bell’s palsy adalah edema dan
iskemia akibat penekanan (kompresi) pada nervus fasialis.
Penyebab edema dan iskemia ini sampai saat ini masih
diperdebatkan. Dulu, paparan suasana/suhu dingin
(misalnya hawa dingin, AC, atau menyetir mobil dengan
jendela yang terbuka) dianggap sebagai satu-satunya
pemicu Bell’s palsy. Akan tetapi, sekarang mulai diyakini
HSV sebagai penyebab Bell’s palsy, karena telah
diidentifikasi HSV pada ganglion geniculata pada beberapa
penelitian otopsi.
ANATOMI
PATOFISIOLOGI
GEJALA
 Patterns of facial palsy.

Timothy J Eviston et al. J Neurol Neurosurg Psychiatry

2015;86:1356-1361

©2015 by BMJ Publishing Group Ltd

 Botulinum toxin injection sites for the treatment of synkinesis.

Timothy J Eviston et al. J Neurol Neurosurg Psychiatry

2015;86:1356-1361

©2015 by BMJ Publishing Group Ltd

 Bell’s palsy and pregnancy – Steroid Treatment
Several recent reviews recognize that steroid treatment improves
recovery in BP. Ramsey et al performed a meta-analysis of
randomized controlled trials on the efficacy of steroids in BP,
finding the incidence of complete recovery improves by 17%.

Maternal risks :
 exacerbation of peptic ulcers, psychosis, fluid retention,
exacerbation of diabetes, and osteoporosis.
Fetal risks :
 adrenal suppression, low birth weight, and an increased risk of
developmental defects when used in the first trimester,
especially cleft palate.

Initial treatment
for complete facial paralysis should consist of prednisone at a dose of 1
mg/kg for 5 days followed by a tapering dose.

Otolaryngology–Head and Neck Surgery (2007) 137, 858-861

 Bell’s palsy and pregnancy –
Antiviral Treatment
Two double-blind randomized controlled trials demonstrate improved
outcomes in BP patients treated with steroids and antivirals compared to
steroids alone.

Nucleoside analogues including valacyclovir and famciclovir are

classified as pregnancy category B and pose little risk to either mother
or fetus.

The potential benefit probably outweighs the risk of using these

medications, though for maximal efficacy antivirals must be given
within 3 days of onset of the paralysis.

Adour KK, Ruboyianes JM, Von Doersten PG, et al. Bell’s palsy treatment with acyclovir and prednisone alone: a double-blind,
randomized, controlled trial. Ann Otol Rhinol Laryngol 1996;105:371– 8.
. It seems that the best results for adults
(age over 16 years) were achieved with
po prednisolone at a dose of 25 mg
twice daily for 10 days (although, for
children, methylprednisolone 1
mg/kg/daily for 10 days, and then
gradually withdrawn for three to five
days did even better). Naturally, the
separate trials cannot be compared
directly, but it seems that po
administration is quite sufficient.
Dexamethason is dear to many
neurologists but has not been tested for
this indication. I would probably go
with the aforementioned prednisolone
dosing, but 6mg of dexamethasone for
10 days could be an alternative
 Regimen Terapi
Corticosteroid regimens should be initiated within 72 hours of
symptoms. Examples include the following:
• Prednisone 1 mg/kg PO or 60 mg/day for 5d, then tapered over
5d, for a total of 10d or
• Prednisolone 25 mg PO BID for 5 d, then tapered over 5 d, for a
total of 10d

If herpes simplex virus (HSV-1 or HSV-2) or varicella zoster virus

(VZV) is suspected as the etiology, an antiviral agent may be
added to the oral corticosteroid, as follows:
• HSV: Acyclovir 400 mg PO 5 times daily for 10d or valacyclovir
500 mg PO BID for 5d
• VZV: Acyclovir 800 mg PO 5 times daily for 10d or valacyclovir
1000 mg PO TID for 5d

Bruce M Lo, 2017, Bell Palsy Empiric Therapy: Empiric Therapy Regimens.
 Eye care
• Manage with tear substitutes, lubricants, and eye
protection.
• Use artificial tears during waking hours to replace
diminished or absent lacrimation.
• Lubricants are used during sleep, and they may be used
during waking hours if artificial tears cannot provide
adequate protection.
• Eyeglasses or shields protect the eye from injury and
reduce drying by decreasing direct contact of air currents
with the exposed cornea.
• Eye patches are ineffective, because unopposed third
nerve function will result in corneal exposure despite best
efforts to approximate eyelid margins.

Bruce M Lo, 2017, Bell Palsy Empiric Therapy: Empiric Therapy Regimens.
Prognosis
More than two thirds of people with Bell’s palsy achieve full
spontaneous recovery. The largest series of people with
Bell’s palsy who received no specific treatment (n = 1,011)
found the first signs of improvement within 3 weeks of onset
in 85% of people. For the other 15%, some improvement
occurred 3 to 6 months later. The same series found that
71% of people recovered normal function of the face, 13%
had insignificant sequelae, and the remaining 16% had
permanently diminished function, with contracture and
synkinesis (involuntary movement accompanying a
voluntary movement). These figures are roughly similar to
those of other series of people receiving no specific therapy
for Bell’s palsy.
Komplikasi