Case 14 Congenital Facial Paralysis



Craig B. Birgfeld

Case 14 Congenital Facial Paralysis

Case 14 A 4-year-old female presents with inability to move the left side of her face since birth.



14.1 Description




  • Complete left-sided, unilateral facial nerve palsy




    • Inferior descent of left oral commissure



    • Inability to completely close left eye with intact Bell’s reflex



    • Left sclera white, without injection/irritation



14.2 Work-Up



14.2.1 History




  • Family history of congenital palsy



  • History of birth trauma



  • Symptoms of dry or irritated eyes



  • Feeding problems or speech difficulties



  • Lack of lateral eye movement (Moebius syndrome)



14.2.2 Physical Examination




  • Observe facial movement during conversation/build rapport with patient



  • Sequentially test facial nerve function of all branches on both sides



  • Test for Bell’s reflex: Hold eyelid open as patient actively tries to close eye




    • This is a protective phenomenon



  • Inspect sclera for signs of irritation/dryness



  • Look for lower eyelid malposition



  • Donor nerves: Test for contralateral buccal branches of facial nerve (smile), ipsilateral nerve to masseter (bite), spinal accessory nerve (shoulder shrug), and hypoglossal nerve (tongue movement)



14.2.3 Diagnostic Studies




  • Obtain computed tomography (CT) scan, only if there is concern for concomitant craniofacial microsomia



14.2.4 Consultation




  • Best managed by a multidisciplinary team: Plastic surgery, pediatric otolaryngology, neurosurgery, pediatrics, speech pathology, child psychology, nutrition, social work, and nursing.



14.3 Patient Counseling




  • Emphasize the need to maintain corneal lubrication to prevent desiccation and ulceration.



  • Discuss the pros and cons of single-stage surgery (nerve to masseter) and two-stage surgery (cross-facial nerve graft).



  • Discuss the timeline of two-stage facial reanimation beginning with cross-facial nerve graft after age 4, followed 6 months later by gracilis free flap.



  • Explain the additional time needed (6–12 months) for movement to begin.

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Jul 17, 2021 | Posted by in General Surgery | Comments Off on Case 14 Congenital Facial Paralysis

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