Facial Palsy
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Clinically Relevant Anatomy
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For more detail on the anatomy of the facial nerve, please see the Facial Nerve page.
The VIIth cranial Nerve has its nucleus in the Pons, and takes a rather winding route before exiting the skull through the stylomastoid foramen. It then passes through the parotid gland, splitting into 5 branches: Temporal, zygomatic, buccal, mandibular and cervical.
Causes of Facial Palsy:
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- Idiopathic
Bell's Palsy - cause not known [1] but likely to be linked to Herpes Simplex infection [2]
Ramsay Hunt Syndrome - linkied to Herpes Zoster infection [3] = a syndromic occurrence of facial paralysis, herpetiform vesicular eruptions, and vestibulocochlear dysfunction. Patients presenting with Ramsay Hunt syndrome generally have a greater risk of hearing loss than do patients with Bell palsy, and the course of disease is more painful. Moreover, a lower recovery rate is observed in these patients.[4]
- Tumour
A tumor compressing the facial nerve can result in facial paralysis, but more commonly the facial nerve is damaged during surgical removal of a tumour. The most common tumour to result in facial palsy during surgical removal is the Acoustic Neuroma (AKA Vestibular Schwannoma). Less commonly, cholesteatoma, hemangioma, Facial Neuroma or partotid gland tumours are the cause.
- Lyme Disease
Infection with Borrelia burgdorferi via tick bites is another cause of facial paralysis. Of patients affected with Lyme disease, 10% develop facial paralysis, with 25% of these patients presenting with bilateral palsy.[5]
- Rare causes include
Neurosarcoidosis, ototis media, Multiple Sclerosis, Moebius Syndrome, Melkersson-Rosenthal syndrome, Guillain-Barre Syndrome
- Trauma, especially temporal bone fractures
Clinical Presentation[edit | edit source]
Paralysis of the muscles supplied by the Facial Nerve presents on the affected side of the face as follows:
Appearance and range of movement:[edit | edit source]
Inability to close the eye
Inability to move the lips eg. into smile, pucker
At rest, the affected side of the face may "droop"
Functional effects:[edit | edit source]
Difficulty eating and drinking as lack of lip seal makes it difficult to keep fluids and food in the oral cavity
Reduced clarity of speech as the "labial consonents" (ie. b, p, m, v, f) all require lip seal
Dryness of the affected eye
Somatic effects:[edit | edit source]
The facial nerve supplies the lachrymal glands of the eye, the saliva glands, and to the muscle of the stirrup bone in the middle ear (the stapes). It also transmits taste from the anterior 2/3 of the tongue. Facial palsy often involves:
Lack of tear production in the affected eye, causing a dry, possibly painful eye, with risk of corneal ulceration.
In Facial Nerve palsy there are 2 problems which contribute towards making the eye dry:
1. The greater petrosal nerve, derived from the facial nerve, supplies the parasympathetic autonomic component of the lacrimal gland. - controlling production of moisture/tearing in eyes.
2. The zygomatic branch of the Facial Nerve supplies Orbicularis Oculi, and the resulting paralysis causes inability(or reduced ability) to close the eye or blink, so the tears (or indeed artificial lubrication in the form of drops, gel or ointment) are not spread across the cornea properly.
Hyperacusis = sensitivity to sudden loud noises
Altered taste sensation
Differential Diagnosis, UMN versus LMN:[edit | edit source]
If the forehead is not affected (ie the patient is able to raise fully the eyebrow on the affected side) then the facial palsy is likely to be a result of a lesion in the Upper Motor Neuron (UMN). Paralysis which includes the forehead, such that the patient is unable to raise the affected eyebrow, is a Lower Motor Neuron (LMN)lesion.
Diagnostic Procedures[edit | edit source]
Laboratory investigations include an audiogram, nerve conduction studies (ENoG), computed tomography (CT) or magnetic resonance imaging (MRI), electromyography (EMG).
Management / Interventions
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Medical Management
Bell's Palsy and Ramsay Hunt Syndrome are treated with corticoteroids (prednisone), given within 72 hours of onset,[6] and this can be accompanied by antiviral medication.
Physiotherapy
- Neuromuscular Retraining (NMR) [7]
- Electromyography (EMG) biofeedback [8]
- Trophic Electrical Stimulation (TES) [9]
Key Evidence[edit | edit source]
jama.jamanetwork.com/article.aspx Combined corticosteroid and antiviral treatment for Bell palsy: a systematic review and meta-analysis. de Almeida JR, Al Khabori M, Guyatt GH, Witterick IJ, Lin VY, Nedzelski JM, Chen JM.
onlinelibrary.wiley.com/doi/10.1002/14651858.CD001942.pub4/abstract Cochrane Review: Corticosteroids for Bell's palsy (idiopathic facial paralysis) Rodrigo A Salinas, Gonzalo Alvarez, Fergus Daly, Joaquim Ferreira
onlinelibrary.wiley.com/doi/10.1002/14651858.CD006283.pub3/abstract Cochrane Review: Physical therapy for Bell's palsy (idiopathic facial paralysis) Lázaro J Teixeira1, Juliana S Valbuza, Gilmar F Prado
Resources[edit | edit source]
www.qvh.nhs.uk/our_services/plastic_surgery_and_burns/facial_palsy.php NHS Facial Palsy Service, Queen Victoria Hospital, East Grinstead
www.cmft.nhs.uk/royal-eye/our-services/facial-function-clinic.aspx NHS Facial Function Clinic, Central Manchester University Hospitals, Manchester
www.facialpalsy.org.uk/ Charity for Facial Palsy from any cause
bellspalsy.org.uk/links.html Bell's Palsy Association, Charity
www.nhs.uk/Conditions/Bells-palsy/Pages/Introduction.aspx Information web-site
Case Studies[edit | edit source]
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Recent Related Research (from Pubmed)[edit | edit source]
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References[edit | edit source]
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- ↑ Peiterson,E. Bell's Palsy; the spontaneous course of 2,500 peripheral facial nerve palsies of different etiologies. Acta Oto-Laryngologica. Supplementum 2002;549:4-30
- ↑ Holland NJ, Weiner GM. Recent developments in Bell's Palsy. BMJ 2004; 329(7465):553-7
- ↑ Hunt JR. On herpetiform inflammation of the geniculate ganglion: A new syndrome and its complications. Nerve Ment Dis. 1907;34:73.
- ↑ Murakami S, Hato N, Horiuchi J, et al. [Clinical features and prognosis of facial palsy and hearing loss in patients with Ramsay Hunt syndrome]. Nippon Jibiinkoka Gakkai Kaiho. Dec 1996;99(12):1772-9.
- ↑ Clark JR, Carlson RD, Sasaki CT, et al. Facial paralysis in Lyme disease. Laryngoscope. Nov 1985;95(11):1341-5.
- ↑ ^ Gronseth, GS; Paduga, R (2012 Nov 7). "Evidence-based guideline update: Steroids and antivirals for Bell palsy: Report of the Guideline Development Subcommittee of the American Academy of Neurology". Neurology 79 (22): 2209–13.
- ↑ Manikandan N. Effect of facial neuromuscular re-education on facial symmetry in patients with Bell's palsy: a randomized controlled trial. Clin Rehabil. 2007 Apr;21(4):338-43.fckLR*Electromyography (EMG) Biofeedback <ref>Bossi D, Buonocore M et al. Usefulness of BFB/EMG in facial palsy rehabilitation. Disabil Rehabil. 2005 Jul 22;27(14):809-15.
- ↑ Bossi D, Buonocore M et al. Usefulness of BFB/EMG in facial palsy rehabilitation. Disabil Rehabil. 2005 Jul 22;27(14):809-15
- ↑ Targan R S, Alon G, Kay SL. Effect of long-term electrical stimulation on motor recovery and improvement of clinical residuals in patients with unresolved facial nerve palsy Otolaryngol Head Neck Surgery February 2000 vol. 122 no. 2 246-252
