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A Systemic Approach To Facial Nerve Paralysis

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Article ID: WMC001856 2046-1690

A Systemic Approach to Facial Nerve Paralysis

Corresponding Author:
Dr. Tan Aik Kah,
Trainee Lecturer, Ophthalmology, Universiti Malaysia Sarawak (UNIMAS), 93150 - Malaysia

Submitting Author:
Dr. Tan Aik Kah,
Trainee Lecturer, Ophthalmology, Universiti Malaysia Sarawak (UNIMAS), 93150 - Malaysia

Article ID: WMC001856

Article Type: Original Articles
Submitted on:08-Apr-2011, 03:19:28 AM GMT Published on: 08-Apr-2011, 07:47:36 PM GMT
Article URL: http://www.webmedcentral.com/article_view/1856
Subject Categories:OPHTHALMOLOGY
Keywords:Facial Nerve Paralysis, Bell\'s Palsy
How to cite the article:Aik Kah T , Hanom Annuar F . A Systemic Approach to Facial Nerve Paralysis .
WebmedCentral OPHTHALMOLOGY 2011;2(4):WMC001856
Source(s) of Funding:
Nil

Competing Interests:
Nil

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A Systemic Approach to Facial Nerve Paralysis

Author(s): Aik Kah T , Hanom Annuar F

Abstract systematic diagnostic approach and recognition of red

flags is important in the approach of facial nerve
paralysis.

Purpose. To present systemic approach and Methods

recognition of red flags in facial nerve paralysis.
Background. Patients with facial nerve paralysis
commonly present themselves to the primary care CLINICAL EVALUATION OF FACIAL PARALYSIS
physicians. Misdiagnosis of other causes of facial The standard order of management includes history,
nerve paralysis as Bell’s palsy is not uncommon. clinical examination, relevant investigations and
Occult malignancy can present with acute facial treatment. An overview management flowchart is
paralysis resembling Bell’s palsy; with no other clinical helpful (Illustration 1).
findings and normal imaging findings. A systematic The differential diagnoses of facial nerve palsy are
diagnostic approach and recognition of red flags is numerous. An extensive review of medical literature
important. from 1900 to 1990 by May and Klein found more than
Conclusion. A careful search for the etiology of facial 50 causes of facial paralysis.5 Upper motor neuron
paralysis will avoid misdiagnosis and medicolegal facial paralysis (UMNL) is caused by diffuse or
complications. Bell’s palsy should always remain a localized intracranial pathologies. The causes of lower
diagnosis of exclusion. motor neuron facial paralysis (LMNL) can be similarly
Introduction divided into systemic and local pathologies (Illustration
2)..
Clinical examinations should include a complete
neurological and systemic examination, otoscopy of
Facial nerve is the seventh cranial nerve. From its
the external auditory canal, the regional skin, lymph
origin in the lower pons, the facial nerve runs a
nodes and the parotid gland. The diagnosis of Bell’s
complex course which consists of pontine,
palsy should be considered last after excluding all
subarachnoid, intratemporal and extratemporal
other possible causes. Nine red flags 2,3,4 which
portions. Patients with facial nerve paralysis commonly
guard against the diagnosis of Bell’s palsy are the
present themselves to the primary care physicians
presence of 1) facial pain, 2) limb weakness, 3)
with unilateral facial drooping. The commonest cause
paresthesia of the face of limbs, 4) cerebellar signs, 5)
of acute facial paralysis is Bell’s palsy. Although
involvement of other cranial nerves, 6) gradual onset
Herpes Simplex virus type-1 is postulated to be the
of facial weakness, 7) previous history of facial
cause, Bell’s palsy remains a diagnosis of exclusion.1
weakness, 8) previous history of regional skin cancer,
A large number of Bell’s palsy patients are managed
and 9) prolonged facial paralysis beyond 6 months.
at the primary health care level. Bell’s palsy is
CLINICAL EXAMINATION FOR FACIAL MUSCLE
considered by many physicians as a straightforward
WEAKNESS 6
diagnosis that is easy to manage. However,
The motor root of the facial nerve innervates striated
misdiagnosis of other causes of facial nerve paralysis
muscles of the second pharyngeal arch, which include
as Bell’s palsy is not uncommon. Morris et al found
the muscles of facial expression (Illustration 3). The
that as high as 28% of patients had symptoms not
five terminal branches of the facial nerve are the
attributable to facial nerve paralysis in patients
temporal, zygomatic, buccal, marginal mandibular and
diagnosed with Bell’s palsy. These include limb
cervical. The temporal branch innervates the forehead
paresis, limb paresthesia and clumsiness.2 On the
muscles and the superior part of the orbicularis oculi.
other hand, Boahene et al and Quesnel et al reported
The zygomatic branch innervates the muscles of the
that occult malignancy can present with acute facial
nasolabial fold. The buccal branch innervates the
paralysis resembling Bell’s palsy; with no other clinical
buccinator and the orbicularis oculi. The marginal
findings and normal imaging findings. 3 , 4 The
mandibular branch innervates the depressors of the
neuroanatomy of the facial nerve is complex but well
mouth and the cervical branch innervates the platysma
characterized. Collateral damage to the many
muscle.
structures along its course provides important clues for
The forehead is controlled by the frontalis, corrugators
the localization of pathological processes. A

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supercilii and procerus muscles. Clinically, the frontalis motility and closure, corneal sensation, blink reflex,
muscle is tested by asking the patient to wrinkle the Bell’s phenomenon and tear production. Patients with
forehead. Asymmetry or weakness of the forehead grade 3 are only able to achieve complete eyelid
wrinkles points towards LMNL, whereas UMNL spares closure with maximal effort, hence are at risk of
the forehead muscles (Illustration 4). exposure keratopathy especially in the absence of
A weakened orbicularis oculi will cause lagophthalmos Bell’s phenomenon.
and in severe cases, paralytic ectropion. The power of NEUROANATOMICAL LOCALIZATION
the orbicularis oculi is examined clinically by asking The diagnostic flowchart for syndromes of UMNL and
the patient to close his or her eyes tightly. Inspect for LMNL facial paralysis are presented (Illustration 6 and
incomplete closure and incomplete buring of 7). The neuroanatomical details are beyond the scope
eyelashes. The eyes are forced open for muscle tone of this manuscript. Readers are advised to refer to
asymmetry. standard neuroanatomy texts for more complete
The nasolabial folds are maintained by the references. Further information is provided by the
zygomaticus major, zygomaticus minor, levator labii excellent works of Nicolai et al 8, Terao et al 9 and
superioris and levator labii superioris alaeque nasi Kim J 10.
muscle. These muscles are tested as a group by In the temporal bone, the facial nerve takes a
asking the patient to smile, show his or her teeth or serpentine course. In progressive order, the facial
pull back the corners of the mouth. The buccinators, nerve gives off parasympathetic fibers, motor branch
by blowing the cheek. The orbicularis oris, by to the stapedius muscle, receiving taste fibers from the
puckering the lips. Depressing the corners of the anterior two-third of the tongue (via chorda tympani)
mouth tests the group of depressor anguli oris, and general sensory fibers. Historically, topognostic
depressor labii inferioris and the mentalis muscles. tests were use to pin point the location of intratemporal
The platysma is usually activated while depressing the lesions. The principle is that lesion distal to the site of
corners of the mouth. a particular branch of the facial nerve will spare the
Subtle weakness of the muscles of facial expression is function of that branch. Recent evidence showed that
noted in the asymmetry of the nasolabial folds and the topognostic tests are of limited clinical value due to
mouth while the eyes are closed tightly. The most marked discrepancies. Inflammation and
subtle signs of facial weakness are the blink reflex and demyelination may involve multiple sites. The
incomplete lid closure. The blink reflex is observed parasympathetic fibers and chorda tympani nerves are
during conversation, or tap gently on the glabella. In damaged more easily in trauma despite intact facial
cases with strong suspicion of facial muscle weakness, nerve. Transmission of nerve impulses occur through
the patient is asked to lie supine, with head slide-off the tumor mass itself until late in the disease with
the examining table so the head is below the body. different areas of the nerve being affected at different
This forces the eyelids to work against gravity. The times.11
patient is asked to close both eyes and inspect for BELL’S PALSY- A DIAGNOSIS OF EXCLUSION
incomplete closure. Gentle glabella tap will elicit Bell’s palsy is an idiopathic condition characterized by
asymmetry in blinking. acute, isolated, unilateral LMNL facial nerve palsy
MEASUREMENT OF FACIAL NERVE FUNCTION 7 involving all the branches of the facial nerve. The
Measurement of facial nerve function is important for weakness is maximal within 48 hours after onset. The
baseline documentation, monitoring of progression or Copenhagen Facial Nerve Study showed 85% of
recovery of facial paralysis and for the comparison of patients had functional recovery within 3 weeks and in
different treatment modalities. The House-Brackmann the remaining 15% after 3 to 5 months.12 Any
grading system has been accepted by the American deviation from the above characteristics warrants
Academy of Otolaryngology-Head and Neck Surgery further investigations for an underlying cause.
as the standard used in reporting facial nerve function. Boahene et al reported 15 cases of occult neoplasm
Although disfiguring facial asymmetry is alarming to presented with acute facial paralysis.3 Eleven patients
most patients, the most devastating complication is were misdiagnosed as Bell’s palsy.
exposure keratopathy which may result in corneal Pain is a common feature in Bell’s palsy. About 70% of
ulceration and blindness. Patients with grade 1 – 3 are patients report pain in or around the ear.2 Pain
able to complete close their eyes (Illustration 5). becomes suspicious if it occurred elsewhere or
OCULAR PROTECTIVE MECHANISMS AND persistent beyond facial paralysis. Malignancy of the
COMPLICATIONS parotid gland is highly suggested by the triad of ear
This is best performed by the ophthalmologists. Five pain, facial paralysis and sensory loss in the second
important ocular protective mechanisms are eyelid and third divisions of the trigeminal nerve.

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Neuroimaging may fail to detect occult malignancy facial reanimation surgeries.

because of the predominant perineural, intraneural,
and perivascular spread of cancer, failure to scan the
entire course of the facial nerve and failure to identify Conclusion(s)
small parotid gland tumor located in the deep lobe or
close to the stylomastoid foramen. Surgical exploration
of the facial nerve is indicated if there is a progressive A careful search for the etiology of facial paralysis will
and prolonged pattern of paralysis without recovery, avoid misdiagnosis and medicolegal complications.
pain, involvement of other cranial nerves, and a history Bell’s palsy remains a diagnosis of exclusion and its
of regional skin cancer.3 management is multidisciplinary. The nine red flags 2,3,4
ROLE OF PRIMARY CARE PHYSICIANS which guard against the diagnosis of Bell’s palsy are
Primary care physicians are in the front line of the presence of 1) facial pain, 2) limb weakness, 3)
management. A careful search for the underlying paresthesia of the face of limbs, 4) cerebellar signs, 5)
etiology will avoid misdiagnosis and possible future involvement of other cranial nerves, 6) gradual onset
medico-legal complications. Ocular protective therapy of facial weakness, 7) previous history of facial
should be initiated as soon as possible with weakness, 8) previous history of regional skin cancer,
preservative-free artificial tear during daytime and and 9) prolonged facial paralysis beyond 6 months.
ointment during sleep. Referral to the respective
specialty (neurologist, ophthalmologist, Abbreviation(s)
otolaryngorhinologist, physiotherapist) are advocated
even in Bell’s palsy, as electrophysiology tests
performed at early stage of the disease are important UMNL: Upper motor neuron lesion
in prognostication. Surgical decompression of the LMNL: Lower motor neuron lesion
facial nerve may be considered in total facial paralysis
by some otolaryngorhinologist. Authors Contribution(s)
In the case of Bell’s palsy, oral prednisolone 60 mg
daily should be initiated as soon as the diagnosis is
made (if there is no contraindications). Axelsson et al. Tan Aik Kah & Faridah Hanom Annuar: equal
found that treatment with prednisolone within 48 hours contribution in the preparation of the manuscript.
achieve higher complete recovery rate in patients
above the age of 40 and less synkinesis in those
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Illustrations

Illustration 1

Overview management of facial paralysis

Illustration 2

Causes of facial paralysis

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Illustration 3

Muscles of facial expression with their respective innervations

Illustration 4

Bilateral supranuclear innervation to muscles of forehead and eyes

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Illustration 5

Simplified House-Brackmann grading system for facial nerve function

Illustration 6

Diagnostic flowchart for syndromes of UMNL facial paralysis

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Illustration 7

Diagnostic flowchart for syndromes of LMNL facial paralysis

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