Look for asymmetry in facial shape or in depth of furrows such as the nasolabial fold. Also look for asymmetries in spontaneous facial expressions and blinking. Ask patient to smile, puff out their cheeks, clench their eyes tight, wrinkle their brow, and so on. Old photographs of the patient can often aid your recognition of subtle changes. Check taste with sugar, salt, or lemon juice on cotton swabs applied to the lateral aspect of each side of the tongue.
Annals of Internal Medicine. See also: List of people with Bell's palsy. Anatomy Image. HMP Communications. This condition is often caused by a stroke. Carpal tunnel syndrome Ape hand deformity. This causes progressive onset of the characteristic unilateral facial paralysis involving the forehead, eye and lower face.
Airbrushed chicks. What is Being Tested?
If you have a patient come in complaining of new or acute onset of unilateral facial paralysis without any other sensory or motor deficits i.
- Central facial palsy colloquially referred to as central seven is a symptom or finding characterized by paralysis or paresis of the lower half of one side of the face.
- Look for asymmetry in facial shape or in depth of furrows such as the nasolabial fold.
- If you have a patient come in complaining of new or acute onset of unilateral facial paralysis without any other sensory or motor deficits i.
- Bell's palsy is a type of facial paralysis that results in an inability to control the facial muscles on the affected side.
Bell's palsy is a type of facial paralysis that results in an inability to control the facial muscles on the affected side. The cause of Bell's palsy is unknown. The condition normally gets better by itself with most achieving normal or near-normal function.
Bell's palsy is characterized by a one-sided facial droop that comes on within 72 hours. The facial nerve controls a number of functions, such as blinking and closing the eyes , smiling , frowning , lacrimation , salivation , flaring nostrils and raising eyebrows.
It also carries taste sensations from the anterior two-thirds of the tongue , via the chorda tympani nerve a branch of the facial nerve. Although the facial nerve innervates the stapedius muscle of the middle ear via the tympanic branch , sound sensitivity , causing normal sounds to be perceived as very loud, and dysacusis are possible but hardly ever clinically evident.
Some viruses are thought to establish a persistent or latent infection without symptoms, e. Reactivation of an existing dormant viral infection has been suggested as a cause of acute Bell's palsy.
Bell's palsy occurs due to a malfunction of the facial nerve cranial nerve VII , which controls the muscles of the face. Facial palsy is typified by inability to control movement in the muscles of facial expression. It is thought that as a result of inflammation of the facial nerve, pressure is produced on the nerve where it exits the skull within its bony canal the stylomastoid foramen , blocking the transmission of neural signals or damaging the nerve.
Patients with facial palsy for which an underlying cause can be found are not considered to have Bell's palsy per se. Possible causes include tumor , meningitis , stroke , diabetes mellitus , head trauma and inflammatory diseases of the cranial nerves sarcoidosis , brucellosis , etc. In these conditions, the neurologic findings are rarely restricted to the facial nerve. Babies can be born with facial palsy. In some research, the herpes simplex virus type 1 HSV-1 has been identified in a majority of cases diagnosed as Bell's palsy via endoneurial fluid sampling.
In addition, HSV-1 infection is associated with demyelination of nerves. This nerve damage mechanism is different from the above-mentioned—that edema, swelling and compression of the nerve in the narrow bone canal is responsible for nerve damage. Demyelination may not even be directly caused by the virus, but by an unknown immune response. Bell's palsy is a diagnosis of exclusion , meaning it is diagnosed by elimination of other reasonable possibilities.
By definition, no specific cause can be determined. There are no routine lab or imaging tests required to make the diagnosis. Other conditions that can cause similar symptoms include: herpes zoster , Lyme disease , sarcoidosis , stroke , and brain tumors.
Once the facial paralysis sets in, many people may mistake it as a symptom of a stroke; however, there are a few subtle differences.
A stroke will usually cause a few additional symptoms, such as numbness or weakness in the arms and legs. And unlike Bell's palsy, a stroke will usually let patients control the upper part of their faces.
A person with a stroke will usually have some wrinkling of their forehead. One disease that may be difficult to exclude in the differential diagnosis is involvement of the facial nerve in infections with the herpes zoster virus. The major differences in this condition are the presence of small blisters, or vesicles , on the external ear and hearing disturbances, but these findings may occasionally be lacking zoster sine herpete.
Reactivation of existing herpes zoster infection leading to facial paralysis in a Bell's palsy type pattern is known as Ramsay Hunt syndrome type 2. Steroids have been shown to be effective at improving recovery in Bell's palsy while antivirals have not. Corticosteroids such as prednisone improve recovery at 6 months and are thus recommended. One review found that antivirals such as aciclovir are ineffective in improving recovery from Bell's palsy beyond steroids alone in mild to moderate disease.
In severe disease it is also unclear. One review found no effect regardless of severity. They are commonly prescribed due to a theoretical link between Bell's palsy and the herpes simplex and varicella zoster virus. When Bell's palsy affects the blink reflex and stops the eye from closing completely, frequent use of tear-like eye drops or eye ointments is recommended during the day and protecting the eyes with patches or taping them shut is recommended for sleep and rest periods.
Physiotherapy can be beneficial to some individuals with Bell's palsy as it helps to maintain muscle tone of the affected facial muscles and stimulate the facial nerve. Surgery may be able to improve outcomes in facial nerve palsy that has not recovered. It is unknown if early surgery is beneficial or harmful. The efficacy of acupuncture remains unknown because the available studies are of low quality poor primary study design or inadequate reporting practices.
Most people with Bell's palsy start to regain normal facial function within 3 weeks—even those who do not receive treatment. The patients who regain movement within the first two weeks nearly always remit entirely. When remission does not occur until the third week or later, a significantly greater part of the patients develop sequelae. Major possible complications of the condition are chronic loss of taste ageusia , chronic facial spasm , facial pain and corneal infections.
Another complication can occur in case of incomplete or erroneous regeneration of the damaged facial nerve.
The nerve can be thought of as a bundle of smaller individual nerve connections that branch out to their proper destinations. During regrowth, nerves are generally able to track the original path to the right destination—but some nerves may sidetrack leading to a condition known as synkinesis. For instance, regrowth of nerves controlling muscles attached to the eye may sidetrack and also regrow connections reaching the muscles of the mouth.
In this way, movement of one also affects the other. For example, when the person closes the eye, the corner of the mouth lifts involuntarily. This is also called gustatolacrimal reflex or Bogorad's syndrome and involves the sufferer shedding tears while eating.
This is thought to be due to faulty regeneration of the facial nerve, a branch of which controls the lacrimal and salivary glands. Gustatorial sweating can also occur. The number of new cases of Bell's palsy ranges from about one to four cases per 10, population per year. It affects approximately 1 person in 65 during a lifetime. A range of annual incidence rates have been reported in the literature: 15,  24,  and 25—53  all rates per , population per year. Bell's palsy is not a reportable disease , and there are no established registries for people with this diagnosis, which complicates precise estimation.
The Persian physician Muhammad ibn Zakariya al-Razi — detailed the first known description of peripheral and central facial palsy. Cornelis Stalpart van der Wiel — in gave an account of Bell's palsy and credited the Persian physician Ibn Sina — for describing this condition before him.
James Douglas — and Nicolaus Anton Friedreich — also described it. Sir Charles Bell , for whom the condition is named, presented three cases at the Royal Society of London in Two cases were idiopathic and the third was due to a tumour of the parotid gland. From Wikipedia, the free encyclopedia. Facial paralysis resulting from dysfunction in the cranial nerve VII facial nerve. See also: List of people with Bell's palsy. February 5, Archived from the original on 8 April Retrieved 8 August Practical Neurology.
Cochrane Database of Systematic Reviews. Elsevier Health Sciences. Archived from the original on Jaypee Brothers Publishers. Otolaryngology—Head and Neck Surgery. Journal of General Internal Medicine. Fundamentals of Neurology.
Germany: Thieme. Clinically Oriented Anatomy. Auris Nasus Larynx. A; Ferri R. G; Vietler E. C; Leonhardt F.
D; Testa J. G; Cruz O. M October International Congress Series. European Archives of Oto-Rhino-Laryngology. For whom the Bell tolls". Annals of Internal Medicine. Annals of Emergency Medicine. Lyme Disease. Centers for Disease Control and Prevention.
Retrieved April 12, Retrieved April 18, American Family Physician. Archived from the original on 27 September Lyme disease" PDF.
Neuro developmental treatment NDT often improves daily functioning and self-help. J Laryngol Otol. Charcot—Marie—Tooth disease Dejerine—Sottas disease Refsum's disease Hereditary spastic paraplegia Hereditary neuropathy with liability to pressure palsy Familial amyloid neuropathy. Laboratory evaluation, when indicated by history or risk factors, may include testing for diabetes mellitus and Lyme disease. Surgical management of Bell's palsy. This can be done in several different ways, some which involve raising the hairline and others that are remove a portion of skin, leaving the hairline intact. Given the safety profile of acyclovir, valacyclovir, and short-course oral corticosteroids, patients who present within three days of the onset of symptoms and who do not have specific contraindications to these medications should be offered combination therapy.
Facial droop spares forehead. Facial Nerve
Central facial palsy - Wikipedia
A year-old-male presented to the emergency department with a chief complaint of one day of left-sided facial swelling and weakness.
He denied facial pain, rash, vision changes, fever or chills. On physical exam he was noted to have mild swelling over the left parotid gland as well as a left-sided seventh nerve palsy without forehead sparing inset. The nerve paralysis was complete including inability to purse lips top left or smile on the left side top right.
He had no other neurologic deficits. His description was of facial trauma causing unilateral facial nerve paralysis. Inflammation of the facial nerve, as it courses through the fallopian canal in the temporal bone, is generally accepted as the mechanism that leads to edema, ischemia and ultimately demyelination of the nerve6.
Diagnosis Recognizing central versus peripheral seventh nerve palsy is the first step in diagnosis. Central facial nerve palsy causes paralysis of only the lower half of one side of the face.
This is caused by damage to the upper motor neurons of the facial nerve. The facial motor nucleus contains two regions with lower motor neurons that supply the muscles of the face.
The ventral region supplies the muscles of the lower face, while the dorsal region supplies the muscles of the forehead. The corticobulbar tracts from the dorsal region cross the brainstem several times while the ventral tracts cross only once; giving bilateral cortical input to the dorsal fibers but unilateral input to the ventral fibers.
Thus unilateral lesions of the corticobulbar tracts will cause paralysis of the lower face while sparing the function of the forehead and eye musculature. In contrast, peripheral seventh nerve palsy occurs when the facial nerve fibers are damaged after exiting the brainstem thus both tracts are affected resulting in paralysis of both upper and lower face muscles.
This causes progressive onset of the characteristic unilateral facial paralysis involving the forehead, eye and lower face. This paralysis may be partial or complete so it is important to compare both sides of the face to determine if the upper face is involved. The most sensitive way to do this is have the patient close the eyes and attempt to keep them closed while the examiner tries to open them.
This can detect subtle weakness of the orbicularis occuli that would be seen only in peripheral seventh nerve palsy. These causes can generally be divided into three categories; infection, trauma and neoplasm. History of possible exposure to Lyme disease is important to ascertain, especially in patients with bilateral facial nerve paresis, as early initiation of antibiotics is necessary to preserve nerve function.
Physical exam with evidence of vesicles or rash suggestive of Herpes Zoster or evidence of otitis media or externa can also help guide treatment. A history of trauma to the temporal bone preceding the facial nerve dysfunction suggests nerve transection or compression secondary to fracture and warrants evaluation by an otolaryngologist. A final known cause of facial nerve paresis is neoplasm, particularly a parotid gland tumor.
A history of gradual onset of weakness, involvement of multiple cranial nerves, recurrent dysfunction or prolonged symptoms is suggestive of neoplastic disease and warrants imaging. While the efficacy of treatment with steroids has been questioned, more recent studies demonstrate clinically significant recovery of nerve function over patients treated with placebo alone4,5.
Despite inclusion of larger clinical studies, they still failed to show clinically significant improvement in neurologic recovery with the addition of antiviral agents. Current best evidence recommends treatment with corticosteroids within 48 hours of symptom onset. References 1. Ann Intern Med ; Clin Oto ; 35, BMC Neurol; , Ann Emerg Med. Arch Otolaryngol Head Neck Surg.
Jackson C, von Doersten P. The facial nerve. Current trends in diagnosis, treatment, and rehabilitation. Med Clin North Am.
Leave A Reply Cancel Reply.