Facial Paralysis

Although Bell palsy is the most frequent etiology, it is a diagnosis of exclusion; one must thoroughly rule out infections, congenital, developmental, and other causes. Serial electrical testing provides objective monitoring of nerve function and may provide some prognostic information regarding future functional status.

Differential Diagnosis

Acquired

• Bell palsy
  –A diagnosis of exclusion; 40% of cases
• Acute otitis media
  –From erosion or dehiscence of facial canal
• Chronic otitis media
  –Nerve compression from granulation tissue
• Herpes zoster oticus
  –Often infects eighth nerve as well, with hearing loss and vertigo
• Lyme disease
  –Usually several weeks after inoculation
• Tumors
  –Temporal bone leukemia, rhabdomyosarcoma of head and neck
• Melkersson-Rosenthal syndrome
  –Relapsing alternating facial paralysis
  –Recurrent facial edema
  –Fissured tongue
• Temporal bone fracture
  –Although most cases involve longitudinal fractures, transverse may also result in hearing loss and vertigo
• Facial wounds
  –Early repair if clean wound
  –Tag nerve for delayed repair if dirty wound
• Iatrogenic
  –After otologic or parotid surgery

Congenital
• Traumatic (associated with prolonged and difficult labor)
• Inherited disorders
  –Myotonic dystrophy: Progressive muscle weakness, facial paresis at birth
  –Albers-Schönberg disease: Osteopetrosis increases bone density, compresses nerve
  • Developmental abnormalities
    –Möbius syndrome: Facial paralysis with 6th cranial nerve palsy
    –Association with coloboma, heart defect, choanal atresia, genital hypoplasia, ear anomalies (CHARGE)
    –Goldenhar syndrome, also known as oculoauriculovertebral (OAV) syndrome: First and second branchial arch abnormalities
    –Asymmetric crying facies: Also called congenital unilateral lower lip palsy (CULLP)

  Workup and Diagnosis

  • History
    –Age of onset, rapid vs slow time-course, duration
    –Prior episodes, trauma, neurologic disorders, ear disease
  • Physical exam
    –Facial movement (e.g., while laughing, crying)
    –Facial symmetry at rest
    –Eye closure
    –Tear production, tongue papillae atrophy
  • Audiologic testing
    –Type of hearing loss predicts site of lesion (SNHL: internal auditory canal or CNS; CHL: middle ear)
  • Imaging studies
    –CT best for detecting pathology within temporal bone
    –MRI with gadolinium: Inflammation of nerve seen as enhancement on scan; predicts poorer outcome
    • Electrical testing
      –Objective means of monitoring function
      –Evoked electromyography (EEMG; electrically records muscle compound action potential; below 10% of normal side [i.e., 90% degeneration] predicts poor recovery; test must be done during first few days of paralysis)
      –Electromyography (EMG): Voluntary action potentials predict excellent prognosis; fibrillation potentials predict poor prognosis; polyphasic voluntary action potentials indicate reinnervation; test most useful weeks after injury

    Treatment

    • Treat underlying cause, if identified
      –E.g., tympanomastoidectomy for cholesteatoma, resection or chemoradiation for malignancy
    • Psychological counseling when studies indicate expected poor prognosis
    • Eye care
      –Prevent exposure and drying of eye: Artificial tears, lubricating ointment, and moisture chamber at night
      –Ophthalmologic exam to rule out exposure keratitis
      –Surgical correction: Tarsorrhaphy, upper lid gold weight or spring placement
    • Pharmacologic
      –Steroids: Recommended, but exact benefit unclear
      –Acyclovir: Suspected viral etiology of Bell palsy
    • Surgery
      –Facial nerve decompression
      –Facial reanimation procedures (nerve and/or muscle grafting and/or transpositions)

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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• Back to symptom: Muscle weakness: Introduction (review 3860 causes)
• Next Book Extract About Muscle weakness: FACIAL PARALYSIS (Differential Diagnosis in Primary Care)
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More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

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