Case 13 Acquired Facial Paralysis



Raman Mehrzad, Albert S. Woo, and Daniel Kwan

Case 13 Acquired Facial Paralysis

Case 13 A 65-year-old female presents with complaint of facial asymmetry after acoustic neuroma resection 10 years ago. She is interested in discussing treatment options to improve the appearance and function of her face.



13.1 Description




  • Complete left-sided facial paralysis



  • Facial asymmetry: Left palpebral fissure widening, left nasolabial fold effacement, right-sided deviation of Cupid’s bow, and inferior malposition of the left oral commissure which demonstrates no movement on smiling



13.2 Work-Up



13.2.1 History




  • Onset of symptoms




    • Etiology: Bell’s palsy, surgery, and stroke



    • Unilateral or bilateral; complete or incomplete



    • Duration and rate of progression: Acute, subacute, or chronic



  • Associated symptoms: Headaches, blurred vision, dry eyes, vertigo, hearing loss, otorrhea, oral incompetence, speech difficulties, snoring, and nasal obstruction



  • History of trauma, infections (Bell’s palsy, Ramsay-Hunt, Lyme disease, TB), neuromuscular disease (Myasthenia Gravis, Charcot–Marie–Tooth, Guillain–Barre), tumors (Neurofibromatosis Type II), diabetes, travel history, pregnancy, family history, and surgical history (otologic surgery, rhytidectomy, parotidectomy)



13.2.2 Physical Examination




  • Perform complete head, neck, and cranial nerve examination



  • Examine all branches of facial nerve (complete or incomplete involvement)




    • Temporal (Frontal): Elevation of forehead



    • Zygomatic: Closure of orbicularis oculi



    • Buccal: Elevation of cheek and oral commissure



    • Marginal mandibular: Depression of oral commissure and lower lip



    • Cervical: Contraction of platysma



  • Eyes: Evaluate eye closure, vision, corneal defects, and ectropion




    • Schirmer’s test (see Chapter 25)



    • Bell’s phenomenon (see Chapter 25): If absent, there is greater concern for corneal injury



  • Evaluate facial movements at rest and in multiple different expressions




    • Assess midline deviation, degree of excursion with movement



    • Assess brow movement, nasal valve function, and oral competence



    • Synkinesis: Involuntary contraction of additional facial muscles with voluntary facial movement—due to aberrant neuroregeneration



  • Assess overall muscle status (hypertonic, normal, or atrophic), voluntary and involuntary movements (synkinesis, dyskinesis, fasciculations)



13.2.3 Pertinent Imaging or Diagnostic Studies




  • Hematologic work-up: Complete blood count (CBC) (evaluate for infection, leukemia) and Lyme titer



  • High resolution contrast-enhanced computed tomography (CT) or gadolinium-enhanced magnetic resonance imaging (MRI)




    • Should include the brain (temporal bone) and parotid gland



  • Possible biopsy: Facial nerve, lip (for salivary tumors), and FNA of parotid mass



  • Electrodiagnostic studies: Nerve conduction studies, electromyography (EMG)



  • Electroneurography (ENoG): Compares amplitude of summation potentials of paralyzed face to normal side

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Jul 17, 2021 | Posted by in General Surgery | Comments Off on Case 13 Acquired Facial Paralysis

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