http://www.fpnotebook.com/

Bell's PalsyAka: Facial Nerve Paralysis, Facial Nerve Palsy

See Also
1. Facial Nerve Injury from Birth Trauma
Definition
1. Idiopathic, acute Facial Nerve paralysis
History
1. Named for Sir Charles Bell (1774-1842) who first described the syndrome
Pathophysiology
1. Facial Nerve inflammation at Geniculate Ganglion (risk of ischemia, demyelination)
Epidemiology
1. Incidence: 15-30 per 100,000 per year
2. No gender predominance
3. Incidence peaks at age 40 years
4. More common in Diabetes Mellitus (comorbid in 10% of cases)
History: Red Flags suggestive of other Facial Nerve Paralysis Cause
1. Gradual onset over >2 weeks
  1. Suggests mass lesion
2. Forehead not involved
  1. Suggests central nervous system cause (supranuclear lesion)
3. Bilateral involvement
  1. Suggests autoimmune Polyneuropathy
4. Recent new medications (e.g. Influenza Vaccine)
5. Recent Tick bite
  1. Consider Lyme Disease
6. Fever
  1. Consider infectious cause such as Otitis Media
7. Rash
  1. Vesicular rash (Herpes Zoster)
  2. Erythema Migrans (Lyme Disease)
Exam
1. Head and neck
  1. Ear canal
  2. Tympanic membrane
  3. Mouth and pharynx
  4. Parotid Gland
2. Neurologic Exam
  1. Cranial Nerve Exam
    1. Test Cranial Nerve 7 bilaterally on lower face and forehead
  2. Extremity Motor Exam and Sensory Exam
3. Skin
Symptoms
1. Idiopathic Facial Nerve Paralysis
  1. Hypoesthesia or dysesthesia (80%)
    1. Glossopharyngeal Nerve dysfunction
    2. Trigeminal Nerve dysfunction
  2. Facial or retroauricular pain (60%)
  3. Dysgeusia (57%)
  4. Hyperacusis (30%)
  5. Vagal nerve motor weakness (20%)
  6. Decreased Lacrimation (17%)
  7. Trigeminal Nerve motor weakness (3%)
2. References
  1. Adour (1982) N Engl J Med 307:348
Signs: General
1. Loss of facial creases and nasolabial fold
2. Corner of mouth droops
3. No furrow over forehead (if upper motor neuron lesion)
4. No closure of eyelid
5. Lower eyelid sag
6. Decreased tear production
7. Preserved facial sensation
Signs: Facial Nerve Grading (House-Brackman)
1. Grade 1: Normal Facial Nerve Function
2. Grade 2: Mild Facial Nerve Dysfunction
  1. Gross
    1. Slight weakness on close examination
    2. Synkinesis slight
  2. Rest: Normal symmetry and tone
  3. Motor Exam
    1. Forehead: Moderate to good function
    2. Eyes: Complete closure with minimum effort
    3. Mouth: Slight asymmetry
3. Grade 3: Moderate Facial Nerve Dysfunction
  1. Gross:
    1. Obvious difference between sides (not disfiguring)
    2. Synkinesis noticeable
  2. Rest: Normal symmetry and tone
  3. Motor Exam
    1. Forehead: slight to Moderate movement
    2. Eyes: Complete closure with effort
    3. Mouth: Slightly weak with maximal effort
4. Grade 4: Moderately Severe Facial Nerve Dysfunction
  1. Gross
    1. Obvious weakness
    2. Disfiguring asymmetry
  2. Rest: Normal symmetry and tone
  3. Motor Exam
    1. Forehead: No motor function
    2. Eyes: Incomplete closure
    3. Mouth: Asymmetric with maximal effort
5. Grade 5: Severe Facial Nerve Dysfunction
  1. Gross: Barely perceptible motion
  2. Rest: Asymmetry
  3. Motor Exam
    1. Forehead: No motor function
    2. Eyes: Incomplete closure
    3. Mouth: Slight movement
6. Grade 6: Total Facial Nerve Paralysis
7. References
  1. House (1985) Otolaryngol Head Neck Surg 93:146
Differential Diagnosis
1. See Facial Nerve Paralysis Causes
Labs
1. Serum Glucose
2. Lyme Antibody titer
Imaging: Indicated for supected central cause (see Red Flags above)
1. MRI Head
Management: Loss of blink reflex
1. Frequent use of Artificial tears
2. Protective glasses with side pieces
  1. Use in outdoors, drafty, dusty areas
3. Avoid grinding, sanding, or sawing
4. At night:
  1. Apply bland ointment (Refresh, Lacri-Lube)
  2. Tape eye shut
Management: Improved prognosis of Facial Nerve paralysis
1. General
  1. Start steroid and antiviral agents within 72 hours
2. High dose Corticosteroids: Prednisone
  1. Adult: 60 mg orally daily for 5 days and then 40 mg orally for 5 days
  2. Child: 2 mg/kg/day (up to adult dosing) for 7-10 days
3. Antiviral agents
  1. Mechanism
    1. Based on reactivated HSV hypothesis
  2. Agents
    1. Acyclovir
      1. Adult: 400 mg five times per day for 7 days
      2. Child (>2 years): 80 mg/kg daily (max: 3200 mg/day) divided every 6 hours for 5 days
    2. Valacyclovir
      1. Age >12 years: 1 gram orally three times daily for 7 days
  3. References
Management: Associated Conditions
1. Otitis Media or Mastoiditis Complications
  1. IV antibiotics
  2. Otolaryngology consultation for possible wide incision of tympanic membrane
2. Herpes Zoster Oticus
  1. See Herpes Zoster for antiviral agents
  2. High dose Corticosteroids (1 mg/kg/day)
    1. Avoid in Diabetes Mellitus, peptic ulcer, Glaucoma
Management: Referral Indications
1. Otitis Media complications
2. Mastoiditis complications
3. Signs of secondary cause
  1. Intracranial lesion or nerve impingement
Prognosis: Factors associated with poor prognosis
1. Worse Prognosis with time needed for recovery
  1. No recovery by 3 weeks suggests worse prognosis
2. Hyperacusis
3. Diabetes Mellitus
4. Hypertension
5. Pregnancy
6. Facial Nerve with severe degeneration by EMG
7. Decreased tearing
8. Age over 60 years
9. Ramsay Hunt Syndrome (Herpes Zoster Virus)
10. Severe pain
  1. Aural pain
  2. Anterior facial pain
  3. Radicular pain
Complications
1. Corneal Ulceration
2. Permanent eyelid weakness
3. Permanent facial asymmetry
Prognosis: Recovery
1. Full recovery in 75% of cases
2. Minimal residual deficit in 10%
3. Moderate to severe deficit in 15%
  1. Facial weakness
  2. Contracture or spasm
Course
1. Maximal weakness at 3-7 days after onset
2. Most cases improve within 3 weeks even without treatment
3. Additional improvement may require up to 6 months
  1. Required for nerve regeneration
4. Recurrence in 8% of cases
References
1. Zalvan (1999) Consultant 39(1):39-48
2. Gilden (2004) N Engl J Med 351:1323
3. Holland (2004) BMJ 329:553
4. Tiemstra (2007) Am Fam Physician 76:997

Facial paralysis (C0015469)
Definition (MSH)	Severe or complete loss of facial muscle motor function. This condition may result from central or peripheral lesions. Damage to CNS motor pathways from the cerebral cortex to the facial nuclei in the pons leads to facial weakness that generally spares the forehead muscles. FACIAL NERVE DISEASES generally results in generalized hemifacial weakness. NEUROMUSCULAR JUNCTION DISEASES and MUSCULAR DISEASES may also cause facial paralysis or paresis.
Definition (CSP)	severe or complete loss of facial muscle motor function; this condition may result from central or peripheral lesions; damage to CNS motor pathways from the cerebral cortex to the facial nuclei in the pons leads to facial weakness that generally spares the forehead muscles; facial nerve diseases generally results in generalized hemifacial weakness; neuromuscular junction diseases and muscular diseases may also cause facial paralysis.
Concepts	Disease or Syndrome (T047)
ICD9	351.0
MSH	D005158
English	Facial nerve palsy, Facial Nerve Paralysis, Facial Palsies, Facial Palsy, Facial paralysis, PARALYSIS FACIAL, Paralysis of facial nerve, Seventh nerve palsy, Seventh nerve paralysis, VII nerve palsy
Spanish	paralisis del nervio facial, paralisis del septimo par craneal, paralisis facial
Parent Concepts	Peripheral Neuropathy (C0031117), Cranial nerve diseases (C0010266), CRANIA NERVE ABNORMALITIES (C0549640), Mouth Diseases (C0026636), Paralysed (C0522224), Facial Nerve Diseases (C0015464), Cranial nerve palsies (C0151311)
Sources	COSTAR, CSP, CST, DXP, LCH, MSH, MTH, MTHICD9, NCI, NDFRT, OMIM, SCTSPA, SNOMEDCT Derived from the NIH UMLS (Unified Medical Language System)

Neurology Book

Infectious Disease

Miscellaneous

Sensory Disorders

Examination Chapter related topics

http://www.fpnotebook.com/

Bell's PalsyAka: Facial Nerve Paralysis, Facial Nerve Palsy

Facial paralysis (C0015469)

Navigation Tree