Table of Contents
- Introduction
- Types of Facial Nerve Palsy
- Etiology
- Pathophysiology
- Figure 1: Showing distribution of facial muscles paralysis following upper motor and lower motor facial nerve palsy
- Table 1: Differences between the lesions of the Facial Nerve
- Sign and symptoms
- Clinical Examination
- Diagnosis
- Prognosis
- Treatment
- Continuity of Care
- Bibliography
Primary Category
Neuroimmunology
P-Category
Secondary Category
S-Category
Introduction
- Facial (nerve) palsy is a neurological condition in which the function of the facial nerve (cranial nerve VII) is partially or completely lost.
- It is often idiopathic but in some cases, specific causes such as infections or trauma can be identified.
Types of Facial Nerve Palsy
- Central or Upper
Lesions occur between cortex and nuclei in the brainstem.
- Peripheral or Lower
occurs between nuclei in the brainstem and peripheral organs.
Etiology
- The most common cause of facial nerve palsy is Bell’s Palsy.
- Idiopathic disease is the second most common cause
- Other causes of sudden one sided facial nerve paralysis include a traumatic head injury, stroke, viral infection such as herpes simplex or herpes zoster
- Rare cause includes Lyme disease and Sarcoidosis
Pathophysiology
- The facial muscles are innervated peripherally (infra nuclear innervation) by the ipsilateral 7th cranial nerve and centrally (supra nuclear innervation) by the contralateral cerebral cortex.
- Central innervation tends to be bilateral for the upper face (e.g, forehead muscles) and unilateral for the lower face.
- Peripheral lesions (facial nerve palsy) tend to affect the upper face more than central lesions (e.g, stroke) do.
- Central and peripheral lesions tend to paralyze the lower face.
Figure 1: Showing distribution of facial muscles paralysis following upper motor and lower motor facial nerve palsy
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Table 1: Differences between the lesions of the Facial Nerve
Differences between the lesions of the Facial Nerve
Sign and symptoms
- pain behind the ear
- paresis
- affected side becomes flat and expressionless
- ability to wrinkle the forehead, blink and grimace is limited or absent
- in severe cases, peripheral fissure widens and the eye does not close
- conjunctiva irritation
- corneal drying
Clinical Examination
- Sensory examination is normal.
- External auditory canal and a small patch behind the ear (over the mastoid) may be painful to the touch.
- If the nerve lesion is proximal to the geniculate ganglion, salivation, taste, and lacrimation may be impaired, and hyperacusis may be present.
Diagnosis
Clinical Evaluation
- Chest x-ray or CT .
- Serum angiotensin-converting enzyme (ACE) levels to check for sarcoidosis.
- Serum glucose is measured to check for diabetes
- MRI if onset was gradual or other neurologic deficits are present.
- Diagnosis is mainly clinical.
Prognosis
- In idiopathic facial nerve palsy, the extent of nerve damage determines outcome.
- If some function remains, full recovery typically occurs within several months.
- Nerve conduction studies and electromyography are done to help predict outcome.
- The likelihood of complete recovery after total paralysis is 90% if nerve branches in the face retain normal excitability to supramaximal electrical stimulation and is only about 20% if electrical excitability is absent.
- Chronic disuse of the facial muscles may lead to contractures and may result in permanent cosmetic damage in 10%.
Treatment
- Corneal drying must be prevented by frequent use of
- Natural tears
- isotonic saline or methylcellulose drops intermittent use of tape or a patch to help close the eye. Tarsorrhaphy is occasionally required.
- In idiopathic facial nerve palsy (Bells Palsy),
- Corticosteroids, if begun within 48 hours after onset, result in faster and more complete recovery.
- Prednisone 60 to 80 mg orally once a day is given for 1 week, then decreased gradually over the 2nd week.
- Antiviral drugs effective against herpes simplex virus
- (eg, valacyclovir 1 g orally 3 times a day for 7 to 10 days, famciclovir 500 mg orally 3 times a day for 5 to 10 days, acyclovir 400 mg orally 5 times a day for 10 days).
- F/U recommendations
- If does not show improvement in 57 days follow up with PCP right away
- Recent data suggest that antiviral drugs provide no benefit.
Refer to SOAP note on Bells Palsy
Continuity of Care
- Inpatient and Outpatient Neurology Follow up
- Outpatient PCP Follow up
- Eye patch for sleep
- Artificial tears as needed
- Order therapies as indicated (Physical, occupational &/or Speech)
Bibliography
- Diagnosing facial nerve paralysis. Patient Care at NYU Langone Health. (n.d.). Retrieved September 24, 2021, from https://nyulangone.org/conditions/facial-nerve-paralysis-in-adults/diagnosis.
- Facial nerve paralysis " learn ENT online " facial nerve paralysis. Learn ENT Online. (2020, October 25). Retrieved September 24, 2021, from https://www.entlecture.com/facial-nerve/.
- Facial Nerve Palsy (Bell Palsy; Bell's Palsy) By Michael Rubin, By, Rubin, M., & Last full review/revision Sep 2020| Content last modified Sep 2020. (n.d.). Facial nerve palsy - neurologic disorders. Merck Manuals Professional Edition. Retrieved September 24, 2021, from https://www.merckmanuals.com/professional/neurologic-disorders/neuro-ophthalmologic-and-cranial-nerve-disorders/facial-nerve-palsy.
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