Cranial Nerve Problems:
Bell’s Palsy
Trigeminal Neuralgia
Chapter 60 and ATI
1
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Trigeminal Neuralgia (TN)
Trigeminal
Neuralgia (TN)
• Also known as Tic Douloureux
• Benign condition but has
considerable pain and lifestyle
disruption from physical and
psychologic dysfunction
• May be related to underlying
pathology
• Shingles, multiple sclerosis, or
cerebellar or brainstem masses
3
Copyright © 2020 by Elsevier, Inc. All rights reserved.
TN…Etiology and pathophysiology
• Trigeminal nerve (CN V): both motor and sensory branches
• TN most often affects sensory branches of maxillary and mandibular
branches
• Vascular compression of trigeminal nerve root, as it exits the
brainstem, by an abnormal loop of the superior cerebellar artery
leading to chronic injury that results in flattening and atrophy of nerve
and damage to myelin sheath
• Characterized by sudden, unilateral, severe, brief, stabbing, recurrent
episodes of pain along trigeminal nerve
• First episode: sudden onset
4
TN…Clinical Manifestations
TN type 1: abrupt onset of waves of excruciating pain
• Burning, knifelike, or lightning-like shock in the lips, upper or lower gums, cheek,
forehead, or side of nose
• Acute attack: facial twitching, grimacing, frequent blinking and tearing
• Facial sensory loss
• Attacks are brief; seconds to 2 to 3 minutes
• Frequency: 1 to over 50 times per day
• Pain starts with trigger; light touch at trigger zone along distribution of nerve
branches
• Stimuli may include: chewing, brushing teeth, hot or cold blast of air, washing
the face, yawning, or talking
TN type 2: less intense pain, but a constant dull aching or burning pain.
5
TN…Clinical Manifestations
• Pain leading to
improper
nutrition,
neglected hygiene,
cloth over face,
social withdrawal
6
Copyright © 2020 by Elsevier, Inc. All rights reserved.
TN…Diagnostic Studies
• History
• Physical and neurologic examinations
• Rule out other disorders causing facial pain
• MRI 3D reconstruction. Magnetic components that photographs cross
section of body. No metal.
• MRA. Magnetic Resonance Angiography. Magnetic field, radio waves and a
computer to evaluate blood vessels and help identify abnormalities.
• Consult: neurology, neuroradiology, neurosurgery, dentistry, maxillofacial
surgery, and pain management
7
Copyright © 2020 by Elsevier, Inc. All rights reserved.
TN…Interprofessional Care
Goal: Pain relief
• Drug therapy
• Analgesics
• Antiseizure drugs
• Tricyclic antidepressants
• Local nerve block with anesthetics or botulinum toxin
• Surgical Therapy
• Peripheral nerve blocks or ablation
• Gasserian ganglion and retrogasserian ablative (needle) procedures
• Craniotomy followed by microvascular decompression
• About 50% of treated patients develop recurrent pain in 12 to 15 years
8
TN…Nursing Assessment
• Assess
•
•
•
•
•
•
•
•
*Triggering factors
Characteristics
Frequency
Pain management techniques
Hygiene; include oral hygiene
Nutrition
Behavior (withdrawal)
Lifestyle disruption
• Drug use
• Emotional state
• Suicidal tendencies
9
Copyright © 2020 by Elsevier, Inc. All rights reserved.
TN
Nursing Management
• Monitor response to drug
therapy and side effects
• Pain management: analgesics
• Complimentary pain
management options
• Acupuncture, biofeedback, and
yoga
• Teach pt to reduce triggers
Patient Education
• Nutrition; easy to chew food;
lukewarm; high protein
• NGT on unaffected side with
enteral feedings
• Hygiene and oral care; complete at
peak of analgesia
• Dental visits semiannually
• Protect face from temperature
extremes (no cold or heat)
• Use electric razor
10
Bell’s Palsy
Bell’s Palsy
• Acute, usually temporary facial paresis (or palsy) from damage to
facial nerve (CN VII); usually unilateral but can be bilateral
• Incidence
•
•
•
•
12
40,000 Americans per year
Affects men and women equally
Peak incidence: ages 15 to 60 years
Often occurs with pregnancy, upper respiratory conditions, and HTN
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Bell’s Palsy – Etiology & Pathophysiology
• Exact cause unknown
• Theories
• Reactivation of herpes virus leading to inflammation and nerve compression
causing clinical features
• Acute demyelination
• Prognosis—very good
• Recovery 2 weeks—6 months
• Some have residual effects
13
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Bell’s Palsy
Facial Characteristics with Bell’s Palsy
14
Fig. 60-15
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Bell’s Palsy – Clinical Manifestations
• CN VII: motor, sensory, and autonomic function
• Key feature: unilateral lower motor facial weakness
• 50% to 60% have pain behind the ear and neck
• Other: drooping eyelid (ptosis) and corner of the mouth, facial
twitching, dryness of eye or mouth, facial numbness, altered taste,
hearing loss, excessive tearing in one eye
• Symptom onset is sudden; peak in 48 to 72 hours
• Quality of life alterations
• Problems with eating, swallowing, taste, and speech
• Psychologic withdrawal due to changes in appearance, malnutrition,
dehydration, mucous membrane trauma, corneal abrasions, muscle
stretching, and facial spasms and contractures
15
Bell’s Palsy – Diagnostic Studies
• Clinical diagnosis; no definitive test
• Physical examination for typical pattern of onset
• Exclude other causes
• CT scan or MRI
• Blood tests
• EMG
• Referrals: neurologist or otolaryngologist
16
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Bell’s Palsy –
Interprofessional and Nursing Management
• Focus: symptom relief, prevent complications, protection of affected
eye
• Oral corticosteroids: start within 72 hours
• Antiviral
• Surgical decompression: refractory cases
• Controversial
17
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Bell’s Palsy - Management
• Pain management
•
•
•
•
•
Mild analgesia
Moist heat
Electrical stimulation
Facial massage
Physical therapy
• Facial muscles
• Sling can support affected muscles, improve lip alignment, and facilitate eating
• Exercises—several times per day when function begins to return
• Protect face from cold to avoid trigeminal hyperesthesia (extreme
sensitivity to pain or touch)
18
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Bell’s Palsy - Management
• Eye protection
•
•
•
•
Dark glasses: protection and cosmetic
Artificial tears: prevent drying of cornea
Ointment and eye shield at night; tape lids
Report eye pain, drainage, or discharge
• Nutrition
• Chew on unaffected side
• Oral hygiene after meals
• Physical appearance
• Can be devastating but good chance for full recovery
• Assure did not have a stroke
• Family and friend support very important
• Encourage social interaction
19
Question
During assessment of the patient with trigeminal neuralgia, the nurse
should (Select all that apply)
A. Inspect all aspects of the mouth and teeth
B. Assess the gag reflex and respiratory rate and depth
C. Lightly palpate the affected side of the face for edema
D. Test for temperature and sensation perception on the face
E. Ask the patient to describe factors that initiate an episode