Osteopathic Manipulative Treatment of a 26-Year-Old Woman With Bell's Palsy

Abstract

Bell's palsy is caused by a lesion of the facial nerve and results in unilateral paralysis or paresis of the face. The condition affects approximately 23 in 100,000 persons, with onset typically occurring between the ages of 10 and 40 years. The authors report the case of a 26-year-old woman with Bell's palsy, whom they treated with osteopathic manipulative treatment that was focused on the enhancement of lymphatic circulation. The osteopathic manipulative procedures used involved reducing restrictions around four key diaphragms (thoracic outlet, respiratory diaphragm, suboccipital diaphragm, cerebellar tentorium), as well as applying the thoracic pump, muscle energy, primary respiratory mechanism, and osteopathy in the cranial field. The authors, who were guided by the four principles of osteopathic philosophy, report that the patient's symptoms resolved within 2 weeks, during which two sessions of osteopathic manipulative treatment, each lasting approximately 20 minutes, were held. Patient recovery occurred without the use of pharmaceuticals.

Full text

JAOA • Vol 106 • No 5 • May 2006 • 285Lancaster and Crow • Student Contribution
Bell’s palsy is caused by a lesion of the facial nerve and
results in unilateral paralysis or paresis of the face. The con-
dition affects approximately 23 in 100,000 persons, with
onset typically occurring between the ages of 10 and 40
years. The authors report the case of a 26-year-old woman
with Bell’s palsy, whom they treated with osteopathic
manipulative treatment that was focused on the enhance-
ment of lymphatic circulation. The osteopathic manipu-
lative procedures used involved reducing restrictions
around four key diaphragms (thoracic outlet, respiratory
diaphragm, suboccipital diaphragm, cerebellar tentorium),
as well as applying the throracic pump, muscle energy,
primary respiratory mechanism, and osteopathy in the
cranial field. The authors, who were guided by the four
principles of osteopathic philosophy, report that the
patient’s symptoms resolved within 2 weeks, during which
two sessions of osteopathic manipulative treatment, each
lasting approximately 20 minutes, were held. Patient
recovery occurred without the use of pharmaceuticals.
J Am Osteopath Assoc. 2006;106:285–289
http://www.jaoa.org/content/vol106/issue5/
B
ell’s palsy (ie, unilateral facial nerve paralysis) is an idio-
pathic, acute condition caused by a lesion of the facial
nerve, resulting in unilateral paralysis or paresis of the face.
Approximately 23 in 100,000 persons per year become afflicted
by Bell’s palsy.1Symptoms, which can affect either side of the
face, typically first occur in patients between the ages of 10 and
40 years.1Bell’s palsy affects men and women at a roughly
equal rate of occurrence.1
The physiologic mechanism responsible for Bell’s palsy
appears to involve inflammation of the facial nerve within the
osseous facial canal, causing compression and ischemia of the
nerve.1A viral cause of Bell’s palsy has been suspected since
the mid-1990s, when the genome of herpes simplex virus–type
1 was isolated from facial nerve endoneurial fluid in patients
afflicted with Bell’s palsy.2Osteopathic physicians commonly
find restricted ipsilateral motion of the temporal bone and
upper cervical restrictions in patients with Bell’s palsy.3The
conventional treatment for patients involves the use of oral
prednisone (60–80 mg daily) for 5 days, followed by a tapering
in dosage for 5 additional days.1
Symptoms of Bell’s palsy may be mild (with only delayed
blinking of the eye on the affected side of the face) or more
severe (including weakness of the eyelid muscles and inad-
equate tear production).1Severe symptoms sometimes
progress to corneal ulcerations. In so-called Bell’s phenomena,
a patient’s affected eye rolls upward whenever an attempt is
made to close the eyelid. Other possible features of Bell’s
palsy include drooping of the corners of the mouth, indistinct
skin folds and facial creases, and an unfurrowed forehead.
During mastication, food may collect between the patient’s
teeth and lips, and saliva may dribble from the corner of the
mouth. Smiling may reveal a marked contrast between the
two sides of the face, with the affected side being expres-
sionless. Depending on where the lesion occurs in the osseous
facial canal, a patient’s taste reception in the anterior two
thirds of the tongue may be altered. A patient may also expe-
rience pain in or behind the ear and hyperacusis.1
Report of Case
In the present case, we used osteopathic manipulative treat-
ment (OMT) focusing on the enhancement of lymphatic cir-
culation to treat a patient with Bell’s palsy. We used no phar-
macologic interventions. During the application of treatment,
we were guided by the four principles of osteopathic phi-
losophy4,5:
䡲The body is a unit.
䡲The body is self-healing and self-regulating.
䡲Structure and function are reciprocally interrelated.
䡲Rational treatment is based on an understanding of the
above three principles.
Patient History
The patient in the present case was a 26-year-old woman
who arrived at the osteopathic manipulative medicine clinic
at the University of North Texas Health Science Center at
Fort Worth—Texas College of Osteopathic Medicine with
right-sided facial weakness, which she said she had for
1 week, accompanied by a dulled sense of taste. She noted that
Osteopathic Manipulative Treatment of a 26-Year-Old Woman With Bell’s Palsy
David G. Lancaster, DO
William Thomas Crow, DO
From private practice in Dallas, Tex (Lancaster), and the Philadelphia Col-
lege of Osteopathic Medicine in Pa (Crow).
Address correspondence to David G. Lancaster, DO, 6659 Aintree Circle,
Dallas, TX 75214-1622.
E-mail: davesbiosphere@hotmail.com
STUDENT CONTRIBUTION

286 • JAOA • Vol 106 • No 5 • May 2006
the day before the onset of her symptoms, she was up all
night studying.
In response to questions, she said she had not experi-
enced trauma or fallen asleep in a drafty room. Nor, she
claimed, did she have previous infection with herpes simplex
virus–type 1, acute or chronic auditory disorders, or recent
dental work. The patient’s medical history was notable for an
incident of facial weakness that lasted for 1 month when she
was 7 years old. The only surgical procedure in her medical
history was a tonsillectomy. During the week prior to her visit
to the clinic, she had noticed only slight improvement of her
symptoms. She said she was not taking any medication.
Physical Examination
The patient’s physical examination revealed weakness of her
right eyelid with delayed blinking, along with a mild right-
sided facial droop and lips that remained flat on the right side
when she attempted to smile. Cranial nerves II through XII
were intact, except for the right facial nerve (CN VII). The
patient’s upper and lower extremity deep-tendon reflexes,
muscle strength, and sensation were grossly intact.
Structural Examination
The patient’s general appearance was most notable for facial
asymmetry with decreased tone on the right side. The struc-
tural examination also revealed a side-bending/rotation dys-
function on the right side of the cranium. Cervical vertebrae
C2 and C5 were side-bent and rotated right. Fascial restric-
tions were found in the patient’s cervical and thoracic outlet
areas. Standing and seated flexion tests revealed iliosacral
and sacroiliac somatic dysfunction on the right side. There was
decreased right sacroiliac motion and right anterior innom-
inate rotation.
Osteopathic Manipulative Treatment
Osteopathic manipulative treatment—applied in two ses-
sions, each lasting approximately 20 minutes—was used to
address the patient’s somatic dysfunctions. Treatment focused
on enhancing the patient’s lymphatic circulation. No medi-
cations were prescribed. First, several osteopathic manipu-
lative (OM) procedures were used to achieve symmetry.
Then, four key diaphragms were treated to aid lymphatic
circulation: the thoracic outlet, the respiratory diaphragm,
the suboccipital diaphragm, and the cerebellar tentorium.6
In the first OM procedure applied, the patient’s right
anterior innominate was treated with the muscle energy
technique while she remained in a supine position. The
patient’s right leg was flexed at the hip and knee until the
restrictive barrier was engaged. She was instructed to extend
her right hip while an osteopathic physician (D.G.L.) applied
an equal counterforce, thus maintaining an isometric con-
traction for 5 seconds. This technique was repeated several
times until symmetry was achieved.5
Next, with the patient in the prone position, sacral rocking
was performed. Pulmonary respiratory flexion and exten-
sion of the sacrum were monitored and exaggerated by
applying a synchronous force at the pulmonary respiratory
axis until symmetrical motion was achieved.5
The first diaphragm treated was the thoracic outlet
(Figure 1). With the patient supine and the physician at the
head of the table, a direct myofascial release was initiated
by placing a thumb in both of the supraclavicular fossae. A
constant force was directed caudad and laterally until a
release was felt.6
While the patient remained supine, her respiratory
diaphragm was treated. The physician performed this pro-
cedure by standing at her side and engaging the abdominal
viscera with a posterior and cephalad vector.6
After this procedure, the thoracic pump technique was
applied. In this technique, the physician applied a rhythmic
force to the patient’s anterior chest wall for 2 minutes.5
The physician corrected the cervical rotational dysfunc-
tions by using postisometric muscle energy. The suboccipital
diaphragm was treated with myofascial and soft tissue tech-
niques to alleviate the cervical and suboccipital fascial restric-
tions and to enhance local circulation. To increase lymphatic
flow around the right stylomastoid foramen and surrounding
tissue, the mandibular drainage technique (ie, Galbreath
treatment) was used (Figure 2). This technique, which involves
passively induced jaw motion to effect increased drainage of
middle-ear structures via the eustachian tube and lymphatics,
was performed by applying a slow repetitive unilateral ante-
rior traction force to the mandible on each side.5
Finally, primary respiratory mechanism and osteopathy
in the cranial field were used to balance the tension mem-
branes and to promote symmetry in temporal bone and
sacral motion. The cerebellar tentorium served as the focus
of this treatment because of its attachments—specifically
its lateral attachments to the temporal bones along the
petrous ridge enclosing the superior petrosal sinuses; its
posterior attachments to the occipital bone forming the
transverse sinuses; its apical attachment to the clinoid pro-
cess; and its attachment to the cerebral falx forming the
straight sinus.3
Lancaster and Crow • Student Contribution
STUDENT CONTRIBUTION
Figure 1 (top, right). To perform thoracic outlet release, the osteo-
pathic physician’s thumbs are placed in the patient’s supraclavicular
fossae, and pressure is applied in a caudal and lateral vector until
release is felt.
Figure 2 (bottom, right). To perform the mandibular drainage
technique (ie, Galbreath treatment), the osteopathic physician’s hand
is placed on the patient’s mandible to apply an anterior tractional
force. This is repeated on both sides.

JAOA • Vol 106 • No 5 • May 2006 • 287Lancaster and Crow • Student Contribution
STUDENT CONTRIBUTION

288 • JAOA • Vol 106 • No 5 • May 2006
Results
The morning after her treatment, the patient reported that
most of her muscle tone had returned and her sense of taste
was again normal. On the third day posttreatment, there
was a 24-hour exacerbation of the symptoms after the patient
consumed two alcoholic drinks. Within 1 week after treat-
ment, however, she had fully regained her sense of taste and
almost all of her facial tone. Only a mild delay in blinking
remained.
The patient’s second treatment session, which took place
1 week after the first session, included all of the OM proce-
dures described above, except for muscle energy technique
for the cervical area. One week after the second treatment ses-
sion, the patient was asymptomatic.
Comment
When using OMT to treat a patient who has Bell’s palsy,
knowledge of the anatomy of the facial nerve as it traverses
Lancaster and Crow • Student Contribution
STUDENT CONTRIBUTION
Figure 3. A lesion along the intratemporal course of the facial nerve
within the osseous facial canal is believed to be responsible for Bell’s
palsy. Intraosseous branches of the facial nerve include the greater pet-
rosal nerve, the stapedius nerve, and the chorda tympani. The six ter-
minal branches of the facial nerve are the buccal, cervical, mandibular,
posterior auricular, temporal, and zygomatic branches.
Temporal Branch
Lacrimal Gland
Eyeball
Zygomatic
Branch
Buccal Branch
Tongue
Sublingual Gland
Mandibular
Branch
Submandibular Gland
Greater Petrosal Nerve
Geniculate Ganglion
Internal Acoustic Meatus
Stapedius Nerve
Region of Lesion
in Osseus Facial Canal
Stylomastoid Foramen
Posterior Auricular Branch
Chorda Tympani
Cervical Branch

JAOA • Vol 106 • No 5 • May 2006 • 289
rium, which attaches to the temporal bone and allows for
physiologic temporal motion. Because of dural attachments
to C1, C2, and the sacrum, somatic dysfunctions in these
areas were addressed.
Contraindications to the use of the manipulations
described in the present study include metastatic disease
and obvious bony fractures.
Conclusion
The application of OM procedures focusing on the enhance-
ment of lymphatic circulation resulted in complete relief of the
patient’s unilateral facial nerve paralysis within 2 weeks—
without the use of pharmaceuticals. Successful treatment
consisted of two sessions, approximately 20 minutes each
and 1 week apart, to free up restrictions found in four key
diaphragms. The results of the present case study suggest that
efficacious treatment of patients with Bell’s palsy can be
based on the four principles of osteopathic philosophy,4,5
incorporating OMT and eschewing pharmacologic
intervention.
References
1. Martin JB, Beal MF. Disorders of the cranial nerves. In: Fauci AS, Braunwald
E, Isselbacher KJ, Wilson JD, Martin JB, Kasper DL, et al, eds. Harrison’s Prin-
ciples of Internal Medicine. 14th ed. New York, NY: McGraw-Hill; 1998:2378.
2. Murakami S, Mizobuchi M, Nakashiro Y, Doi T, Hato N, Yanagihara N. Bell
palsy and herpes simplex virus: identification of viral DNA in endoneurial
fluid and muscle. Ann Intern Med. 1996;124(1 pt 1):27–30. Available at:
http://www.annals.org/cgi/content/full/124/1_Part_1/27. Accessed March 28,
2006.
3. Magoun HI. Osteopathy in the Cranial Field. 3rd ed. Boise, Idaho: North-
west Printing; 1976:27–28,269.
4. Rogers FJ, D’Alonzo GE, Jr, Glover JC, Korr IM, Osborn GG, Patterson MM,
et al. Proposed tenets of osteopathic medicine and principles for patient
care. J Am Osteopath Assoc. 2002;102:63–65. Available at:
http://www.jaoa.org/cgi/reprint/102/2/63. Accessed March 22, 2005.
5. Ward RC, ed. Foundations for Osteopathic Medicine. Baltimore, Md:
Williams & Wilkins; 1997:4,720–721,780–790,843–849,955–959.
6. Speece CA, Crow WT. Ligamentous Articular Strain: Osteopathic Manip-
ulative Techniques for the Body. Seattle, Wash: Eastland Press;
2001:93,146–147,161–168.
7. Moore KL, Dalley AF. Clinically Oriented Anatomy. 4th ed. Philadelphia,
Pa: Lippincott Williams & Wilkins; 1999:1097–1102.
8. Guyton AC, Hall JE. Textbook of Medical Physiology. 10th ed. Philadelphia,
Pa: WB Saunders; 2000:162–174.
the temporal bone is important in understanding the nature
of symptoms.
The facial nerve enters the internal acoustic meatus,
located in the petrous portion of the temporal bone, where it
begins its intratemporal course (Figure 3). Within the facial
canal lies the geniculate ganglion, which supplies general
and special nerve cell bodies for taste and cutaneous sensa-
tion of the external acoustic meatus. Intraosseous branches of
the facial nerve include, in descending order, the greater pet-
rosal nerve, the stapedius nerve, and the chorda tympani.
The petrosal nerve provides parasympathetic innervation of
the lacrimal gland. The stapedius nerve innervates the
stapedius muscle, allowing dampening of loud sounds, and
the chorda tympani supplies taste to the anterior two thirds
of the tongue and parasympathetic innervation of the sub-
mandibular and sublingual glands. The facial nerve exits the
cranium through the stylomastoid foramen to give rise to
six terminal motor branches leading to the muscles of facial
expression (Figure 3).7
This anatomic knowledge allowed us to deduce that the
patient’s lesion was most likely at the chorda tympani. This
deduction was also supported by the patient’s altered sense
of taste and the lack of tearing and auditory disturbances.
Inflammation within the facial canal, as seen in patients
with Bell’s palsy, affects the function of the facial nerve and
its intraosseous branches by causing ischemia and compres-
sion. To restore a patient’s fluid balance, proper lymphatic
flow is important. Lymph can take in large proteins and par-
ticles that may not otherwise be absorbed directly into the
blood. It can also deliver these proteins as nutrients to cells.
Lymph is the first line of defense against bacteria, viruses, and
toxins, which are destroyed by passing through lymph nodes.
Although bone does not contain lymph channels, it does
have prelymphatic channels through which interstitial fluid
can flow. Lymph circulates in a low-pressure system that
relies primarily on interstitial fluid pressure and the pumping
effect of extrinsic muscle contractions. When the muscles
intermittently contract, they compress the lymph vessels and
one-way valves within these vessels, allowing for unidirec-
tional flow. When tissue inflammation occurs, lymphatic
flow is impeded and edema ensues.5,8
The osteopathic treatment plan described in the present
case study focused on the enhancement of the patient’s lym-
phatic flow by freeing up restrictions found in four key
diaphragms: the thoracic outlet, respiratory diaphragm, sub-
occipital diaphragm, and cerebellar tentorium. Treatment of
the patient began in the area of the thoracic duct and thoracic
outlet with myofascial release of the supraclavicular fascia and
use of the thoracic pump technique. The respiratory
diaphragm was treated to allow for deeper breathing, thus
creating greater pressure gradients to aid in lymphatic flow.5
Primary respiratory mechanism and osteopathy in the cranial
field were used to release restrictions in the cerebellar tento-
Lancaster and Crow • Student Contribution
STUDENT CONTRIBUTION