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thank you. Thank you very much, Hanna and everyone. Just a quick aside, Hannah, if by any chance, as a brief wife, I cut out for me, I have also posted the full talk as well. Um, so welcome, everyone. It's a It's an honor to be here with you all. I'm going to talk to you today about an aspect of neurology which is very commonly seen in in actual general practice, and not just by neurologists. So what I'm talking about is talking about facial weakness. And I wonder if this stage, if Hannah please let me know if there are any problems with vision about seeing my presentation or about hearing me. If not, I will keep going on. So what I'm going to be talking to you today about is facial weakness. It's really common. It's incredibly. It can be incredibly disabling for patient's because when we look at people, usually the first thing we look at is their face. And even a slight discrepancy can be very disturbing for patient's. In particular, I'll be looking at Bell's palsy, which is the commonest idiopathic cause for one sided facial weakness. So that's me. Um, if you've been to previous lectures, you would have seen me before. So that's me. I'm an associate professor of teaching at the Queen Square Institute of Neurology, and that's a picture of the Queen Square Institute of Neurology. It's the less attractive building on the left, and I am also an honorary consultant neurologist at the building on the right, which is the National Hospital for Neurology and Neurosurgery. But enough of that. There's just a little thing I always need to add, which I think I've added. Yes, I have about the images here. As an educator, I'm allowed quite a lot of license under fair use to use, for example, illustrations from published journals. But it doesn't mean I've got copyright for them, so you find to use them for your own educational use. But please don't kind of post them or anything else. I'm sure you wouldn't so put a name to the face. Now I'm firstly actually want to give great credit to patient's like this, who gave their consent, obviously, to the original publishers, because it must have been quite distressing for them. But it's very helpful for us, and I'd like you just to think just for a few seconds about what you actually see here, because it may seem easy on paper to say yes, someone's weak on one side of their face, but it's most evident when they're trying to smile, and so actually it can come across. You start thinking, which is the abnormal side, particularly if you don't know. Are they smiling? Or are they still now? In fact, as you can probably see on your right hand side, that's the patient's left side. She is actually trying to smile. And so that's week. You notice that the nasal labial fold on your right, her left is not as prominent on the other side, and you can see she can't really shut her eye on that side. And, as I'll explain later, that I am particular is really helpful in indicating a lower motor neuron palsy. But just a little reminder that if you didn't know that she was trying to smile, it's possible the abnormal side could be the other side, because there is something called Hemifacial spasm where you actually get a spasming up without wanting to move your face at all. But this is indeed weakness of the face, although not Bell's palsy. As I go on to say so. Bell's Palsy, What's it all about? Well, Bell's palsy is a common acute facial mono neuropathy, so mono neuropathy means one nerve. It affects about one in 5000 year and about three quarters or just over of cases of acute lower motor neuron. Seventh nerve palsy, possibly a little bit under that equal numbers male or female. There are some risk factors, even though it's idiopathic. If you've got HIV or Type two diabetes or a family history of Bell's palsy, you maybe it's slightly increased risk. It's thought quite widely that at least many cases may actually be a manifestation of the reactivation of herpes viruses you can see like herpes simplex virus. These type of viruses are really, really nasty, but chicken pox virus they give you, they give you the infection. And then they often just hide, often for many, many decades, and then can come out, particularly when people's immunity is compromised. So here is the man himself, um, and by the man himself. I mean the I mean Charles Bell, who was actually a Scottish surgeon who who actually served at the Battle of Waterloo. Um, and he was. He was in his late forties when he first described Bell's palsy that bears his name. So let's think about testing the facial nerve. Those of you who would have attended my talk on neurology examination would know already that there's a kind of a bit of a system to it. And when you're doing your cranial nerves, of course, eventually you come to the seventh cranial nerve, which is the facial nerve. So with the facial nerve, you might recall, you sort of test if they can raise their eyebrows. They can shut their eyes a little word on that, particularly elderly people. If they can shut their eyes so they're burying their eyelashes. That's enough. Don't start trying to force them open with great force, because you'll achieve it with older people, and it's not very nice. If they can bury their eyelashes, that's full power. Can they puff out their cheeks? Most importantly, can they smile and grimace? Most useful Ever smile and shut your eyes. That's because those will rapidly tell you smile. You very rapidly see an asymmetry to suggest one sided weakness. She shutting the eyes usually tells you if it's upper or lower, so people with a stroke can often shut their eyes but not smile If they've got facial weakness. People with Bell's palsy that's the lower motor neuron will often not be able to smile and not be able to shut their eyes properly. The classic description, as I've just said there is between peripheral weakness. That's the lower motor neuron. You're just affecting the nerve versus central weakness, typically on the other side of the brain, which affects more centrally like a stroke. So here we've got a picture of two types. So on your left, the image shows a bell's palsy type picture. So affected is the nerve. And if you affect the nerve on one side of the face, perhaps not surprisingly, the whole of the face on that side will be week. If looking now at the picture on your right. Instead of that, there's like a stroke. So this is something on the other side on the brain, taking out the bit that controls your facial movements. In that case, oddly enough, the end result looks better because there's some crossover, so there's some sparing of the motor signal. You almost get a bit of help from the other side as well. But that's only above the eyebrow eyes. So basically you get some sparing of raising your eyebrows and also some sparing of shutting your eyes. That's why the eyes are so important. In both examples, they probably won't be able to smile very well. But with a stroke or a central cause of facial weakness, they may well be able to shut their eyes still, even if they can't smile properly. Now. One little thing I have with this picture. Obviously I've given the reference there. This shows a closed eye for Bell's palsy, but I think it's worth adding that very often the I won't be have to close. So So I've added that in just as an aide memoire to you, and that's important. Later, when we come onto protection of the eye, there are a couple of things you don't normally test on a cranial nerve exam. But they're important for this talk because they also functions which the which the facial nerve can do special sensation. The taste taste from the anterior two thirds of your tongue is from the facial nerve effectively or via the cord a tympani. And then there's also a parasympathetic flow stimulating salivation. Now these are important points that I will come back to a bit later. So what do you actually see? And again, it can be a bit more difficult than you might think you might think. Well, surely it's easy to see if someone's got weakness on one side of their face, but particularly at rest. Most of us are not kind of smiling or grimacing. We just got to sort of just at rest face. This is a picture from again. I've given the reference there, and it's very subtle, but actually there is a bit of a difference. On the left side, you can see the slight drooping of the mouth and on the left side, that's the patient's left. Sorry, so you're right. The patient's left. You see those drooping of the mouth, possibly a little bit of a loss of the nasal labial fold on her, left your right and the I actually looks more open. And that's because, of course, there's difficulty in closing the eye with Bell's palsy. That's quite subtle. So what do you actually see? Well, again. I've given the reference here when it's a more profound case of Bell's palsy. You see all of that, and it may be really obvious when they try and shut their eyes that they can't shut the eye on that side. But I want to give you a very useful little tip. You actually see something unusual. It looks unusual, but it's actually totally normal now. You wouldn't know it, perhaps, and, you know, surprise me once upon a time. But when we shut our eyes, we actually tend to roll our eyes up. You don't see it because the eyelids are coming down. That's presumably a protective mechanism. But when you can't shut the eyelids, then you still see the eye rolling up. That's called Bell's phenomena, and actually it's very striking when you see it in a patient, and it can be a real clear indicator that you know about what's going on now. Bell's phenomena, where humans are not the only animal, actually, that rolls their eyes up as a reflex when closing their eyes. It's obviously sensible as a protective mechanism because the front of the eyes the most sensitive. So if someone is some some objects coming towards your eye. Of course you blink, but you might not know. You're I also rolls up for protection. Great. White. Sorry. This is just to help you remember it as an educational age. Great white sharks actually also roll back their eyes when they bite their pray for protection. Except in jaws. Sorry, everyone. I think the doctor has some WiFi issues. So, um, let's give him a few minutes to rejoin the meeting. Sorry. Apologies for that. Everyone. There was a brief, brief and dip in my wife. I apologies. I shall actually resume where I left off. Many apologies for that. So I'm just going to share my screen again, So let's just get that up. Um, Hannah, can you hear and see me? All right. I'm sorry about that. Yeah, it's all fine now. Yeah. Brilliant. You haven't missed anything because I saw immediately when it cut out. And I'm not going to go back to that shark picture again. Um, except to say that this is bells phenomena. So you haven't missed anything. It's the same idea that when you have a facial weakness, a lower motor neuron facial weakness, you can see the eye rolling up like in this image here. So I've covered that there. This was actually in a patient with with AIDS so moving on from here rather than just say someone has a week face, you can actually grade it. In the 19 eighties, there was this house Brackman scale, but it's a little bit complex. You have to like, get a ruler and measure the eyes and the lip. And so this slightly simpler version has been published as well, which gives you an idea of how you can roughly grade and there's grading like 123 and so on. And this is obviously more severe as you go down. You don't need to learn this as a medical student, but it's useful to know about it. What about treatment? Well, there's been evidence sort of around the years, and it hasn't really recently changed. The bottom line is if someone comes in with Idiopathic Bell's palsy, then you would look to you, would look to treat it typically with steroids, unless there's a clear Contra indication. That's as long as they attend within the 1st 72 hours. There, various different ways that you could give it. There are some suggested ways there from different publications, but the key thing is that you always always check with the most up to date local guidelines so you'll see there that Prednisolone was given. Often, steroids alone are given if there's evidence of other conditions you might think about, added A C added acyclovir, and I'll come onto that in a minute or even valacyclovir. So that's one suggestion there. So I've gone through that so and I will mention that again. But basically so the treatment really revolves around steroids as long as there's not into contra indication. If you're sure it's Bell's palsy and they come within three days of onset, it's a short course of steroids. Remember, steroid use over long term, so longer than 10 days can be a problem because your body starts getting used to it. And if you suddenly take steroids away over, you know, if they've been on it for a couple of weeks, you can start to actually suppress the adrenal glands with that. So usually these are short, sharp treatments of steroids. You always have to check no contraindications. You always have to go through the side effects with the patient, as with any drug use. So what about the others? I said Bell's palsy makes up maybe 80% or possibly two thirds of acute onset, one sided lower motor neuron facial weakness. What else can cause this picture? Well, let's look at one case. Have given the name there this. It's actually the lady from the front of the talk. You remember. She is trying to shut, shut her eyes and smile. But what's happened is on her left your right. She can't. This looks like Bell's palsy, but importantly, it's not. Look at the ear on the affected side. You'll see that they're little horrible. Postural is there or vehicles? This is a classic sign of Ramsay Hunt syndrome, So this is varicella zoster virus reactivation. This is incredibly important to pick up, so if you see someone with facial palsy, you need to look in their ear and document it. If you see this, they will need acyclovir or another antiviral as well as steroids. It's also true to remember you should look in the air not just for physicals, but sometimes very severe infections or even tumours of the air can cause one sided facial weakness. There's another case here. Now this is the case of a child. Let's imagine the background is that they developed a rash and bad pains in one arm and shoulder. Since about a week ago, I'm going to give you all a massive clue which may not be clear from the history. So you might need to ask this from the history he remembered camping in the woods a few weeks before. There were lots of deer in the woods. A few days ago, he developed headaches and bilateral facial weakness. Now, some of you won't know because I've given you all the clues there that what we're talking about is actually not that uncommon in Europe and including in Ukraine. I believe so. This is Lyme disease and Lyme disease, or neuroborreliosis. ISS is often missed, but one of its classic presentations is often bilateral. Lower motor neuron facial weakness. You can see they're trying to shut their eyes, but they can't. Okay, there is a specific treatment for this, which is not steroids and antivirals. So you've got to consider it in the people of Lyme that I've seen, they never seem to remember that they've been bitten by a tick unless you ask them very specifically. And it's worth asking. Have you been near dear recently? Although deers are not the only vectored there. The classic Fechter. So it's worth remembering particular. Many apologies, everyone. I do apologize for the drop out again. Um, I will continue exactly where I was. Many apologies. Um, please let me know Hannah, if you can't hear and see me, but I will go on as I did. There was only a few seconds lost there. So, um, so this was the case as a set of Lyme disease. You need to remember if there's any suspicion. Were they bitten by a tick? Particularly if it's bilateral facial weakness, particularly if it's a child, Very importantly, at the bottom of the screen bilateral facial weakness. You need to think of other things, too, Like Joan Barry syndrome, progressive ascending weakness without reflexes or myasthenia. So myasthenia looks like a lower motor neuron condition. It is, but that's fatigue weakness. So they may say I'm fine and they move their mouth and everything around, and then it gets weak so you can always consider myasthenia with any weakness in neurology, and you simply test by it. But test for it by asking the patient to repeat the motions again and again and see if they get weaker. So moving on again. Let's consider the anatomy now to think of another case that could occur. This is the parts of the brain, the homunculus which supply different parts of the body. You see the faces represented. The bit I want you to look at is this. Look at the brain stem. This is actually the ponds. You see that? Actually, the what happens here is the nucleus subdue. Since that's the sixth nerve which moves your eye outward is very close to the seventh nerve as it forms in the ponds. In fact, the seventh nerve wraps around it. So you get any kind of problem stroke or inflammation in the ponds in this area, and you're likely to get both a lower motor neuron, facial weakness and weakness of the eye looking out. If you see that combination, they should have an MRI scan of their of their brain stem while their brain basically assuming they're contraindications. So let's look at a case. This case has the patient trying to smile, so you'll probably see. They're also trying to lift their eyebrows. And you might see that on the patient's right. Your left. They've got a lower motor neurone weakness. They can't lift their I up. They can't smile. So her problem is on her right side, your left. But she also said, I've got double vision. She looks up, down and so on. And the problem is, actually when she looks to her right is very subtle, but she can't move her. I write the way out, so she's got exactly what I was talking about. Lower motor neuron facial weakness seventh plus a sick from that side. And although it's tiny, you have to believe me. There's a little dot on the A, which is a tiny stroke, it looks miniscule. This is how you actually test for a stroke. You use an MRI. Use the you use a diffusion weighted image, which is on a which lights up like a Christmas tree when you see a stroke. But then you need to compare to check that it's restricted diffusion with the apparent diffusion coefficient map on your right. OK, the key point, though, If you have facial weakness, remember to test the eye movements. We're coming near the end. There's not much more to do. Could it be functional? And by that I mean, is it necessarily an illness which is causing weakness? Because But even a lot Sometimes people do say I've got a little bit of weakness and you can't really see much. My thought is that actually, with any kind of functional condition, you have to be really careful in diagnosing. It may be the case, but be extra careful that you've excluded any proper organic cause in reality. In my experience, often functional weakness actually goes hand in hand with a real weakness, which is there. Distraction is really important. One thing I found really useful is rather than just a smile. Just say what makes you laugh? And that's particularly important when you're looking at central causes of weakness and you can very quickly pick up. If there's a bit of a weakness there, examine the mouth and you can say Show me your teeth more. Also, there may be other nonorganic signs if you really were going down the functional route, and I must stress again that this is not your first port of call. It's like the last port of call when you're sure it's not Bell's palsy. Sure, it's not a stroke, exactly, but it is common. And so you might, for example, see, see, perhaps that there's a Hoovers sign. So Hoover's sign are very quickly show you not to do a bell's palsy. This is a very common sign in neurology. If they're lying on the bed, OK, imagine both their legs. They're okay. You say, Lift up the leg and they say, Oh, it's terribly weak. Okay, Now, without knowing it, when we lift up her leg properly, the other leg pushes down into the bed. Yeah, so you put your hand under the leg they say is weak and then say Lift up your good leg. They lift up the good leg and you'll feel the apparently bad leg pushing down. Now. It's not catching people out. People aren't doing this to trick you, but it's important general thing. If you see a lot of these features, there may be a little big element of other aspects. It's not blaming the patient. It's actually trying to support them and explain these signs which are really common in medicine and which can be very scary for the patient. So that's kind of a bigger picture there. But I want to zoom back into talking about talking about facial weakness from organic cause I've got a few little pointers there about functional conditions. But remember, again, functional is very important. Very common. Perhaps 30% of neurology consult, but you have to put it last. Not first. Okay, you've got to deal with all the potential serious stuff first. Okay, so let's have a It's a bit like a summary slide. This Okay, so it's covering some of the things that we've already looked at, and the first thing we've looked at is is it really a lower motor neuron lesion at all? And to emphasize again, the eyes are really important here. So lower motor neuron facial, unilateral facial weakness. They usually can't smile, but they also can't shut their I. So it seems a bit paradoxical, but lower motor neuron is worse than upper motor neuron upper motor neuron. You can still raise your eyebrows and shut your eyes. Then you would want to see, as I've mentioned already, that you should check eye movements. I mean, you should, of course, to a full neurological exam, of course. But if they also have 1/6 nerve palsy on the same side as the facial weakness, they should ideally have an MRI scan looking at the ponds. Areas of inflammation or a stroke could be present there. Then, if you've got if you've got a progressive picture of lower motor neuron, that's important to investigate. Usually, Bell's palsy gets at its worse. Within a few days, there might even be some pain behind the air. And then, for most people about you know, three quarters over the next few months, it gradually improves, often significantly. But if, on the other hand, it's getting worse and worse, there could be something else. There could be a tumor or something else going on, I've mentioned already. Although Bell's palsy could, in theory be bilateral, it's very unlikely. So investigate. I mentioned Lyme disease earlier. Ask about background risks such as tick bites for Lyme HIV, pregnancy, cancer, ear infections. Look in the ears and I should have said as well on the hard palate for those vehicles that may suggest Ramsay Hunt syndrome and a reactivation of varicella virus I safety is really, really important and often forgotten. People might say, Okay, we've got We've got Bell's palsy. What do we do? Well, I'm covering that again. Here. You can see the treatment. I'm not saying this is the exact treatment. Different different versions have been developed over the years, and, as always, check your local guidelines and local up to date guidelines and contraindications before prescribing any drug. But in general terms, if it's Bell's palsy in the first three days that they present, then you can give high dose steroids so you might consider antivirals if it's Ramsay Hunt or if it's a very severe facial palsy. But again refer to your local guidelines, but going back to the point above about ice safety. If you think about it, If it's Bell's palsy and if they can't shut their I, there's a reason we shut her eyes. All the time is to keep our eye lubricated. So if you're like that all the time, your eyes going to get dry and you can get serious abrasions. People can even lose their site. So this is a real important thing, So artificial tears these are readily available over the counter, not just once a day six or maybe more times a day into the affected eye. And then you can. If you can't shut the I shut the eye properly when they're sleeping, then a gentle bit of of poor of poorest tape might actually be helpful. Well should be considered in that case. So now we're going to cover some of that again because we're talking about prognosis and complications. So even before steroids were widely used. So basically, when there was no treatment for Bell's palsy, some signs of improvement were noted in 70% or more by three weeks, and full recovery was seen in 70% although it might take best part of a year. And that was even before steroids came on. But nevertheless, not everyone has such a good time. And sometimes, sadly, the paralysis can be longer term, and there can be other complications Now. I mentioned again corneal damage, and that's with a good reason. It's so easy to forget. Okay, we think, Oh, sure, the eyes, the face is weak, but it's the problem of not being able to shut your eyes. That's the most acute problem. You don't want them to lose their sight. Remember artificial tears and not just twice daily, very, very regular. Then I've mentioned already what we tend to call microporous tape, lightly applied not on the eye but over the eyelid. If they can't shut their I at night so they don't wear it during the day, it's just at night. We go to sleep, and we wouldn't get the warning irritation if our I was starting to get dry. Now, sadly, 0.2. Sometimes there's only partial recovery, and occasional well, physiotherapy can be useful anyway, but it just occasionally botulinum toxin or reanimation surgery. Even it sounds very dramatic, might be needed. This is not immediate treatment, but sometimes sadly, when people have not responded well after a long time. Now sink, I notice, is a very unusual thing. What I'm going to talk about now is sync. Chinese is if you think about it. What happens is the facial nerve on one side has been damaged. Now some of it might try and sprout and try and find another way around, or indeed, other nerves nearby might sprout and try and pick up where that facial nerve has now no longer innovating like the muscles of the eye. For example, Now the muscles I don't mean moving the eye. I mean of the of the shutting of the eye itself, so the superficial facial muscles will sometimes end up being innovated by other muscles. And so what can happen is that you get maybe the maybe the orbicularis oculi innovated incorrectly. So what can happen is when the mouth is puckered. That's one part of the facial nerve. It might also activate your eyes, and this is something called Sing Kinesis. So look at this picture. This is someone who had effectively. Let's call it Bell's palsy. Actually, Ramsay hunt on her right side. That's your left side sometime before. What happens is that when she when she actually tries to pucker her mouth, then what happens is the eye on the right side closes. So it's like doing this. It's a very strange thing and quite disabling, of course, for a patient to do so. Moving that away, that was 0.3. There's another unusual symptom that can occur because of aberrant re innovation. So what can happen is this bow garage syndrome, so called crocodile tears. So what can happen is there are secreta motor fibers of the facial nerve they supply for salivation. So normally, when you're when you're, you know, getting hungry, you'd salivate because of that supply from the facial nerve. But then, sometimes what can happen if the facial nerve is coming back in? It can aberrantly innovate the lacrimal glands. So you know the tear glands. So what can happen is you're feeling hungry. Yeah, I'm getting my mouth watering and you start to cry. Okay, that's called and borrow, borrow Garrard syndrome or crocodile tears. You may have heard of the term of crocodile tears. It's a quite widely used expression, and it means when tears are artificial or false a little aside just to help me remember this, that in the medieval times this is where crocodile tears come from. It was noted that sometimes, or suggested, sometimes crocodiles seemed to be tearing their eyes when they eat, and in fact it can actually occur. But their explanation at the time was that the crocodile was either feeling sorry that had eaten the food or just possibly trying to lure people in to feel sorry for it. so it could then eat them. So that's the origin of crocodile tears. But in the context of our talk today, they can occur due to aberrant re innovation of the facial nerve as it tries to recover. And instead of just going to the mouth, it accidentally goes up to the lacrimal glands and accidentally triggers tearing of the eye when you're salivating. So I've covered that there. There's a little thing you might have heard of there, which is different, but it has the same general idea. So what can happen is sometimes near the Porotic, you can get another form of damage, which can actually cause gustatory sweating. So that means when you're feeling hungry and salivating, you actually start sweating. But that's a different thing, and it's not related to Bell's palsy. So this is a little bit of my background. I've participated in advisory panels in the past. Um, just always good to declare that we finished well ahead of time. Despite I'm sorry to say, a couple of dropouts briefly for WiFi. Um, and if you have any questions at all, please do let me know. Thank you very much and I can see as it has got, his has got to got their hand up. Yes, sir, we cannot say that the, uh, this facial weakness or Bell's palsy can complete. Be idiopathic until investigated, Right? Um, yes, that's a good question. So I think, as it was asking, Can you just say it's idiopathic or can you do need to investigate every case? I think this is a bigger point here, which is worth emphasizing. I think increasingly, as time goes on and we get more investigations, the temptation is always to say that we have to investigate everything, but actually you're justified. If it's a barn door, absolutely clear cut case of Idiopathic Bell's palsy, then you are actually allowed to treat it as such. But you continue to monitor the patient for several reasons. So let me explain my answer. If someone comes in and let's imagine they're pregnant as well, maybe just to give them another risk factor. And they say, You know what? I've got pain behind my ear. The last few days I've felt sudden weakness on one side of the face. It's a clear lower motor neuron facial weakness. There's no sixth nerve palsy. There's no vehicles in the ear. There's no history of cancer. There's nothing else to worry you. Then it is reasonable to treat that clinically as Bell's palsy. But things can change over time, so you would ideally follow that patient up, if only for their I care, but not just for that. So you can make sure that they're improving, as you would expect most cases with Bell's palsy to do. If, of course, things are getting worse. Or if you have any suspicions, maybe it's bilateral. Maybe there were vehicles in the air that need treating for Ramsay Hunt. Maybe there's 1/6 nerve palsy that needs an MRI, absolutely. But the thing is, this is quite a common condition. And so if every single person who had a clear cut Bell's palsy had MRI's and lumber punctures, then not only would that be a kind of waste of resources, but there are actually risks in doing that. And I just want to mention as an aside, you might think there are no risks about doing MRI s. I'm not talking about metal fragments here. I'm talking the fact that even in young fit people, very commonly, you see dots and spots which can terrify people, even if you know that they're probably going to be fine. So MRI, of course, need to be used when they need to be used. But I think it is totally reasonable. If you think that you have seen a clear cut case of Bell's palsy and you can document it and you're going to follow them up, that is reasonable to treat them. And, of course, you'd explain to the patient about your diagnosis and treatment. Um, were there any other questions at all? Yes, compared to the sink kindnesses where the, uh, I think the sink Sinuses is completely automatic, as in the body itself tries to regenerate an hour propagates, you know, compared to like a neuro surgeon who does the bed if it'll surgery, it's different. Yes, yes, that's right. Yes, it is a bit different. It's I mean, it could be similar. Firstly, I want to answer. There was a question in the comments I had written L M n. I think I'd explained it once, but it actually stands for lower motor neuron. I will get back to your question as that, but just so it's clear so L. M N is lower motor neuron. So what that means is basically the nerve itself, like Bell's palsy, whereas if something's in properly in the spinal cord or above, it's nearly always upper motor neuron. The one weird exception to that, if you remember, was when I was talking about one sided lower motor neuron, facial weakness and sixth nerve palsy. Although the damage there is in the ponds in the brain stem, it's actually a lower motor neuron picture because the nerve is already forming in the ponds. So it's a weird thing. Although the damage seems to be within the brain stem it presents as a lower motor neuron lesion. I'm getting back to your question is add, which is about, you know, is it voluntary? So sink in is is just to remind you all someone say has facial palsy. Bell's palsy say months or even years ago on this side. Okay, they make a fairly good recovery, but when they try and smile or pucker their lips, they shut their I. What's happening here is when the nerve recovered because it must have recovered for them to get better. Not all the individual nerve fibers went back to the right place. You might remember the facial nerve has all these different branches, and sometimes the branches that supply here creep up and start supplying the muscles that shut the eye. And so when you smile or pucker your lips, you sometimes put those two together, so it's because they haven't gone back correctly. I think the similar thing can happen eventually after surgery, because any damage peripheral damage to a facial nerve can potentially do that. It's almost like their friends are trying to help them out. Maybe they realize this isn't properly innovating, but it innovates it in a rather unhelpful way because then you get your eyes shutting tied to your smiling. So that's what Singh Kinesis is. And I think many people would not find it proper who don't understand what sink dining sisters might take it in the wrong way. And places where which are a bit conservative, would be more difficult to explain this. Oh, yeah, absolutely. And and this is again. It's a very sensitive area. I have so much, so much heart and sympathy for patient's. I can't imagine what it would be like even though it's a common phenomenon to walk around the streets, and people look at you like you'll be weird, let alone with sing kinesis. You may have recovered your ability to smoke, but if you're kind of winking in some areas of society, that'd be really people think that they're being rude, and it must be awful for these patient's. And although early prednisolone can help and where needed antiviral medications like acyclovir can help, sometimes people really do need more desperate, not desperate, but more dramatic measures, even occasionally, surgery. I've only had to refer a couple of people ever for reanimation surgery, but you know it can have lasting impact. The good news, however, is that for most people with Idiopathic Bell's palsy, they will recover pretty well, although it can take a period of time, Uh, hunts Ramsay Hunt, which is due to the, uh, chicken pox varicella so sta. It's also possible that it would all show show the rashes, the trunk or the body body trunk as well at the same time. But it's showing that the, uh, you ever sickles it's a confirm, but is it possible that the trunk of the body, the rashes might also come up it up. Yes, so So, Yes. So it's a sensible question. So as it were, basically wondering if it if Ramsay Hunt syndrome. You remember Ramsay Hunt is where it looks like Bell's palsy. But then you look in the air and they've got vehicles because sometimes you could surely diagnosis well, if some, it would not be Bell's Ramsey something as simple a pimple or something at the ear or something. A bump and some might misdiagnose it as a, uh, Grant Ramsay Hunt. Yeah, it's actually, to be honest, is that it's more the more the other way that what happens is people don't look in the air. And they say This is Bell's palsy Because if you if you people is still debating, you know, should you or shouldn't you give antivirals for Bell's palsy? Probably not, but Ramsay Hunt. You must give antivirals, so the greater danger is missing Ramsay hunt. And although you make a good point, this can be viewed a bit like shingles. You know shingles where you get a strap of these vehicles from reactivation of chicken pox. But remember, with shingles, it's very unusual to get more than one strip. If you do, you need to think about people being immunocompromised. So basically this is the strip, but the strip isn't a great thing across the face. It's the inside of the ear, the hard palate. And sometimes I believe, even the tip the tip of the nose. But it's not obvious, but it's a real danger of it's missed because you just give them steroids and what they need is antivirals. So it's a bit like always checking the eye movements when you've got one sided facial weakness. Always look in the air, look in the hard palate and say there were or there weren't vehicles. And incidentally, it's good to look in the ear anyway because, you know, rare tumors and things can develop in the air and cause a progressive facial weakness just the same way that parietal sorry porotic gland tumor's can also cause facial weakness. But this goes back to my point about following patient's up. If they're getting worse, not better, then you need to think again. Then it's unlikely just to be Bell's any other questions at all? Um, sorry, I can't I can't see the thank you. I can't see the chat. We're just looking through the chap. Yes, so that's fine. There were a few questions while you were talking. Yes, was one asking, Why do pregnant ladies have an increased risk? I don't know if it was Yes, it's a very good question. I think there could be a number of factors. One thing I think they're not certain about this is because when the ladies are pregnant, they often get a degree of swelling throughout their body. You may well be aware that there's an increased risk of carpal tunnel syndrome in ladies that are pregnant. And typically, the explanation given is simply because this is a narrow tunnel for the median nerve to go through and if it's swollen or gets any bit puffed up around the nerve, not the nerve being inflamed. But the tunnel gets, you know, a bit more Adam Attar's. Then it's more likely to be to be pushed and maybe get carpal tunnel. The same way with the facial nerve when it comes out from the skull is quite a narrow little hole. And so again, if there's kind of any soft tissue swelling at all, even very slight, then that might impact upon the nerve slightly. That's my best explanation. I'm sure there are other reasons as well, but that's just one thought. Why, why? It seems to be a little bit more common in pregnant ladies. Um, and there's nothing there but question, um, you said we we should create, um, Lyme disease with viral antiviral is always like, Yes, yes, I'll just clarify that. Thank you. Thank you, Tyro for that question. So the question was about Lyme disease. Now I don't want to overplay Lyme disease. If you get someone with a classic bell's palsy, they come within three days. There's nothing unusual. No sixth nerve palsy, no vehicles. It's one side only. It's lower motor neuron. There's nothing else going on. No risk factors. Then you don't need to push it hard. If, however, someone comes from an area, perhaps where you happen to know there's a lot of Lyme disease. Maybe if they live out in the forests or they work with animals, particularly deer, or they report a tick bike, then that's different equally, even if they don't have those factors. But they come in not with the standard bells but with bilateral lower motor neuron facial weakness. Then yes, you definitely should should should consider Lyme. And if that occurs, remember what I said. There are other conditions, like Jeon barriers syndrome that you might have heard of, which can also present a bit like that. But with neon Barry, you typically get a rising weakness across the whole body and loss of reflexes. So if it's simple, Clear Bell's palsy. By all means, you can ask, Have you had any tick bites or anything? But if they don't answer, yes, you don't need to start testing every patient that has Bell's palsy for for Lyme disease. Um, there's another question in the chat. Now, uh, we're asking, Can patient have both lower and upper motor neuron lesion? If so, how can we know? That's a very good question. Well, yes, I suppose they could. Theoretically, it would be tricky, because with neurology, I know it's a bit artificial, but we always try and think of one lesion to explain things, and if it's a lower motor neuron lesion affecting the face, it will be on the same side as the weakness. If it's an upper motor neuron affecting the face, basically, you can assume it will be on the other side. So to think of a single lesion that causes both at once is unlikely. I suppose you could be very unlucky and get a stroke and Bell's palsy at the same time. But you know, that would be very unlucky. And almost certainly, if that was the case, there would be other signs. So, of course, if you get a stroke, it's very, very unusual just to present with facial weakness, there'd be weakness on that side of the body. So the point about the lower motor neuron is it typically only affects the seventh cranial nerve. So if you're if you've only got the seventh cranial nerve affected and it's a low amount of pattern, I think you can assume it's only lower. If, however, you see a lower motor neuron pattern and you see other things like the sixth nerve palsy or weakness down the arm, then it could be an unusual manifestation of a brain stem stroke. But, yeah, it's a good question, but I think in practice it's not much of a problem. Um, when I can see a question there, how long does it take for Bell's palsy to to subside after treatment. Well, firstly, not every case gets better, but the majority will. You might remember that I said in my talk that actually even before there was treatment. So back in the days decades ago when people were just watched then, actually, the majority of people just get better. At 70% or so, people will get better, but it can take months. It might even take nine months to get better. For some people, that can be much quicker. And, you know, there are people I've known that you know, four or five weeks and you know they're feeling fine again. For other people. It's more typically months, and I think being careful, you don't over promise to patient's. So give them hope. You can say the majority of people recover, but that can take time. It's very individual will continue to watch you to support you and follow up and and sorry, yes, I can see that's a similar question. The duration of duration of treatment for Bell's palsy. So, um, I did mention this, and you might have noticed from my talk almost deliberately used two different doses regimes, because there are different doses regimes. But in a nutshell you would want to give steroids. Typically oral prednisolone typically say a dose like 60 mg once daily in adults. If no contra indication, and if you explain the side effects of the patient, you would then typically give it for a duration of about, say, a week to 10 days in total. So it's a short course you might remember that I mentioned. It's a bigger picture way outside this topic. In medicine, steroids are often used if you give steroids for longer than 10 days, particularly longer than two weeks, there's a real danger if you've given high doses for a long time and suddenly stop that the body almost gets lazy from producing. Mineralocorticoid is to support our BP, and they can suddenly drop their BP violently. Um, someone asked, Can Bell's palsy also create with present with eighth nerve palsy? It's theoretically possible, but actually the eighth nerve is a little bit below the seventh, and you probably need to have something quite substantial in the brain stem to be causing that. It is also true to say that some conditions can creep around the edges. Some you know, things like tuberculosis. Meningitis can go around the outside and pick off nerves, as can some malignancies, so it would be a very unusual connection. But if you see something unusual, if it's not a simple Bell's palsy, almost certainly you should investigate further. Um, physiotherapy was asked about, and I I must confess I'm not a physiotherapist, so I don't know the exact regimes they use, but yes, I think physiotherapy is probably under used. Um, I know, you know, it may be difficult to get a physiotherapist, but to to actually give give instructions to the patient can be useful. They can get them to do a number of routines with their face on a regular basis. And one thing I think this is useful for is not only can it genuinely help, but I think it empowers the patient. I think it must be horrible with conditions like this, where the patient may feel powerless. They feel one day they just got a weakness, and they've just got to take tablets, and it feels like any power has been taken away. One of the great things about physiotherapy is it relies not on the physio mainly, it relies on the patient doing the activities. So in a way they're regaining power, and that can actually be a really important thing. And there's a question about Bell's pausing, causing permanent damage. Sometimes it can. It's the minority of cases and for most most cases, definitely the majority. There would be great hope, but I can't promise 100%. And there are some cases where it's longer term. But actually, in most cases you would expect to see at least some improvement. Um, and to be honest again, if things are not improving as they should be, that's probably a time where you should be thinking about further investigations anyway. To see, is it simply a Bell's palsy? Or could something else be going on? So, uh, what you explained earlier sorry to cut you is that, uh, the the lower motor neuron. Uh, like, um, we might have abnormal presentation because in Douma motor neuron, uh, begins, actually, forms from the brain stem is always, uh, mhm. Yeah, the basic basic. Basically, I don't want to confuse with that that that's a rare exception that that a bit about the brain stem but almost ignored because, you know that's like, really rare. But what's really common is just the nerve. So the nerves come out of the brain stem. It's on its way to the facial muscles, and it gets affected probably where it comes out of the skull. So that's basically what we think Bell's palsy is. So only the facial, only the facial nerve, the seventh nerve as it comes out. So that thing about the brain stem that was really, really small print. It's really rare. Most things that affect you in the spinal cord or the brain. Most things are upper motor neuron if they affect that. So that's the simple take home message. This is a very rare exception, as I said, that can occur if you get a problem in the ponds at this particular spot where the seventh nerve is forming around the sixth nerve. But please don't remember that. Remember that Bell's palsy is the main cause, and that's just the seventh nerve with all its branches as they come out from the skull. So that is the main cause of Bell's palsy. Just the seventh nerve, which is lower motor neuron. Um, thank you very much doc. Thank you. And thank you, everyone, for such such interesting questions as well, Thank you. I really appreciate that participation. I just wanted to say thank you. Because I believe this is your last lecture in this, um, in this series in this town. Yeah, I think it is, actually. Yes, I think it is. Well, thank you, everyone, then, for for having me. And thank you, Hannah, for your amazing moderation, as always. Thank you very much. Thank you for giving of your time and for your amazing lectures. I'm sure everyone really appreciates it. Um Well, thank you. And my apologies for the wife I cut out. No. Yeah. Yeah. It's a common struggle nowadays. That's great. Well, thank you all very much. And thankfully, we've finished just on time because there's a couple of minutes before the next lecture. So I wish everyone a safe Christmas and New Year. Stay safe. And thank you very much for allowing me to give you this presentation, which I hope is of some use to you. Thank you. Thank you very much. Um, and since we have another minute also left, please do the feedback form everyone and I'll post a certificate in the chat. Um, I'll be ending the meeting in a minute. Thank you. Okay. Thanks, Hannah. Thanks, everyone. I'll leave now. Please do give him the feedback is always helpful for all of us. That we're always trying to improve things. Thank you very much indeed. Thanks then. By