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Semin Neurol 2021; 41(06): 673-685
DOI: 10.1055/s-0041-1726358
Review Article

Approach to Facial Weakness

Yujie Wang 
1   Department of Neurology, Johns Hopkins University, Baltimore, Maryland
,
Camilo Diaz Cruz
1   Department of Neurology, Johns Hopkins University, Baltimore, Maryland
,
Barney J. Stern
1   Department of Neurology, Johns Hopkins University, Baltimore, Maryland
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Abstract

Facial palsy is a common neurologic concern and is the most common cranial neuropathy. The facial nerve contains motor, parasympathetic, and special sensory functions. The most common form of facial palsy is idiopathic (Bell's palsy). A classic presentation requires no further diagnostic measures, and generally improves with a course of corticosteroid and antiviral therapy. If the presentation is atypical, or concerning features are present, additional studies such as brain imaging and cerebrospinal fluid analysis may be indicated. Many conditions may present with facial weakness, either in isolation or with other neurologic signs (e.g., multiple cranial neuropathies). The most important ones to recognize include infections (Ramsay-Hunt syndrome associated with herpes zoster oticus, Lyme neuroborreliosis, and complications of otitis media and mastoiditis), inflammatory (demyelination, sarcoidosis, Miller–Fisher variant of Guillain–Barré syndrome), and neoplastic. No matter the cause, individuals may be at risk for corneal injury, and, if so, should have appropriate eye protection. Synkinesis may be a bothersome residual phenomenon in some individuals, but it has a variety of treatment options including neuromuscular re-education and rehabilitation, botulinum toxin chemodenervation, and surgical intervention.

Keywords

facial palsy - facial paralysis - Bell's palsy - cranial nerve VII - cranial neuropathy


Publication History

Article published online:
26 November 2021

© 2021. Thieme. All rights reserved.

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  • References

  • 1 Bleicher JN, Hamiel S, Gengler JS, Antimarino J. A survey of facial paralysis: etiology and incidence. Ear Nose Throat J 1996; 75 (06) 355-358
    CrossrefPubMedGoogle Scholar
  • 2 Ge XX, Spector GJ. Labyrinthine segment and geniculate ganglion of facial nerve in fetal and adult human temporal bones. Ann Otol Rhinol Laryngol Suppl 1981; 90 (4, Pt 2): 1-12
    CrossrefPubMedGoogle Scholar
  • 3 Gupta S, Mends F, Hagiwara M, Fatterpekar G, Roehm PC. Imaging the facial nerve: a contemporary review. Radiol Res Pract 2013; 2013: 248039
    Google Scholar
  • 4 Phillips CD, Bubash LA. The facial nerve: anatomy and common pathology. Semin Ultrasound CT MR 2002; 23 (03) 202-217
    CrossrefPubMedGoogle Scholar
  • 5 Hong HS, Yi B-H, Cha J-G. et al. Enhancement pattern of the normal facial nerve at 3.0 T temporal MRI. Br J Radiol 2010; 83 (986) 118-121
    CrossrefPubMedGoogle Scholar
  • 6 Katusic SK, Beard CM, Wiederholt WC, Bergstralh EJ, Kurland LT. Incidence, clinical features, and prognosis in Bell's palsy, Rochester, Minnesota, 1968-1982. Ann Neurol 1986; 20 (05) 622-627
    CrossrefPubMedGoogle Scholar
  • 7 Morris AM, Deeks SL, Hill MD. et al. Annualized incidence and spectrum of illness from an outbreak investigation of Bell's palsy. Neuroepidemiology 2002; 21 (05) 255-261
    CrossrefPubMedGoogle Scholar
  • 8 Chang Y-S, Choi JE, Kim SW, Baek S-Y, Cho Y-S. Prevalence and associated factors of facial palsy and lifestyle characteristics: data from the Korean National Health and Nutrition Examination Survey 2010-2012. BMJ Open 2016; 6 (11) e012628
    CrossrefPubMedGoogle Scholar
  • 9 Eviston TJ, Croxson GR, Kennedy PGE, Hadlock T, Krishnan AV. Bell's palsy: aetiology, clinical features and multidisciplinary care. J Neurol Neurosurg Psychiatry 2015; 86 (12) 1356-1361
    CrossrefPubMedGoogle Scholar
  • 10 Walker HK. Cranial nerve VII: the facial nerve and taste. In: Walker HK, Hall WD, Hurst JW. eds. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd ed.. Boston, MA: Butterworths; 1990. . Accessed January 26, 2020 at: http://www.ncbi.nlm.nih.gov/books/NBK385/
    Google Scholar
  • 11 Reich SG. Bell's palsy. Continuum (Minneap Minn) 2017; 23 (2, Selected Topics in Outpatient Neurology): 447-466
    PubMedGoogle Scholar
  • 12 House JW, Brackmann DE. Facial nerve grading system. Otolaryngol Head Neck Surg 1985; 93 (02) 146-147 available at: https://medicine.uiowa.edu/iowaprotocols/house-brackmann-facial-paralysis-scale
    CrossrefPubMedGoogle Scholar
  • 13 Baugh RF, Basura GJ, Ishii LE. et al. Clinical practice guideline: Bell's palsy. Otolaryngol Head Neck Surg 2013; 149 (3, Suppl): S1-S27
    CrossrefPubMedGoogle Scholar
  • 14 Valls-Solé J. Electrodiagnostic studies of the facial nerve in peripheral facial palsy and hemifacial spasm. Muscle Nerve 2007; 36 (01) 14-20
    CrossrefPubMedGoogle Scholar
  • 15 Fuller G, Morgan C. Bell's palsy syndrome: mimics and chameleons. Pract Neurol 2016; 16 (06) 439-444
    CrossrefPubMedGoogle Scholar
  • 16 Gronseth GS, Paduga R. American Academy of Neurology. Evidence-based guideline update: steroids and antivirals for Bell palsy: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology 2012; 79 (22) 2209-2213
    CrossrefPubMedGoogle Scholar
  • 17 Sullivan FM, Swan IRC, Donnan PT. et al. Early treatment with prednisolone or acyclovir in Bell's palsy. N Engl J Med 2007; 357 (16) 1598-1607
    CrossrefPubMedGoogle Scholar
  • 18 Engström M, Berg T, Stjernquist-Desatnik A. et al. Prednisolone and valaciclovir in Bell's palsy: a randomised, double-blind, placebo-controlled, multicentre trial. Lancet Neurol 2008; 7 (11) 993-1000
    CrossrefPubMedGoogle Scholar
  • 19 Gagyor I, Madhok VB, Daly F, Sullivan F. Antiviral treatment for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev 2019; 9: CD001869
    PubMedGoogle Scholar
  • 20 Adour KK, Ruboyianes JM, Von Doersten PG. et al. Bell's palsy treatment with acyclovir and prednisone compared with prednisone alone: a double-blind, randomized, controlled trial. Ann Otol Rhinol Laryngol 1996; 105 (05) 371-378
    CrossrefPubMedGoogle Scholar
  • 21 Yoo MC, Soh Y, Chon J. et al. Evaluation of factors associated with favorable outcomes in adults with bell palsy. JAMA Otolaryngol Head Neck Surg 2020; 146 (03) 256-263
    CrossrefPubMedGoogle Scholar
  • 22 Peitersen E. Bell's palsy: the spontaneous course of 2,500 peripheral facial nerve palsies of different etiologies. Acta Otolaryngol Suppl 2002; 549: 4-30
    CrossrefPubMedGoogle Scholar
  • 23 Hohman MH, Hadlock TA. Etiology, diagnosis, and management of facial palsy: 2000 patients at a facial nerve center. Laryngoscope 2014; 124 (07) E283-E293
    CrossrefPubMedGoogle Scholar
  • 24 Hato N, Kisaki H, Honda N, Gyo K, Murakami S, Yanagihara N. Ramsay Hunt syndrome in children. Ann Neurol 2000; 48 (02) 254-256
    CrossrefPubMedGoogle Scholar
  • 25 Sweeney CJ, Gilden DH. Ramsay Hunt syndrome. J Neurol Neurosurg Psychiatry 2001; 71 (02) 149-154
    CrossrefPubMedGoogle Scholar
  • 26 Murakami S, Hato N, Horiuchi J, Honda N, Gyo K, Yanagihara N. Treatment of Ramsay Hunt syndrome with acyclovir-prednisone: significance of early diagnosis and treatment. Ann Neurol 1997; 41 (03) 353-357
    CrossrefPubMedGoogle Scholar
  • 27 Steere AC, Strle F, Wormser GP. et al. Lyme borreliosis. Nat Rev Dis Primers 2016; 2: 16090
    CrossrefPubMedGoogle Scholar
  • 28 Halperin JJ. Neuroborreliosis and neurosyphilis. Continuum (Minneap Minn) 2018; 24 (5, Neuroinfectious Disease): 1439-1458
    PubMedGoogle Scholar
  • 29 Marques AR. Lyme neuroborreliosis. Continuum (Minneap Minn) 2015; 21 (6 Neuroinfectious Disease): 1729-1744
    PubMedGoogle Scholar
  • 30 Kaiser R. Variable CSF findings in early and late Lyme neuroborreliosis: a follow-up study in 47 patients. J Neurol 1994; 242 (01) 26-36
    CrossrefPubMedGoogle Scholar
  • 31 Halperin JJ, Shapiro ED, Logigian E. et al; Quality Standards Subcommittee of the American Academy of Neurology. Practice parameter: treatment of nervous system Lyme disease (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2007; 69 (01) 91-102
    CrossrefPubMedGoogle Scholar
  • 32 Cadavid D, Auwaerter PG, Rumbaugh J, Gelderblom H. Antibiotics for the neurological complications of Lyme disease. Cochrane Database Syst Rev 2016; 12: CD006978
    PubMedGoogle Scholar
  • 33 Ellefsen B, Bonding P. Facial palsy in acute otitis media. Clin Otolaryngol Allied Sci 1996; 21 (05) 393-395
    CrossrefPubMedGoogle Scholar
  • 34 Soudry E, Joshua BZ, Sulkes J, Nageris BI. Characteristics and prognosis of malignant external otitis with facial paralysis. Arch Otolaryngol Head Neck Surg 2007; 133 (10) 1002-1004
    CrossrefPubMedGoogle Scholar
  • 35 Garcia-Monco JC. Tuberculosis. In: Biller J, Ferro JM. eds. Handbook of Clinical Neurology. Vol 121. Neurologic Aspects of Systemic Disease Part III. Elsevier; 2014: 1485-1499
    Google Scholar
  • 36 Zunt JR. Tuberculosis of the central nervous system. Continuum (Minneap Minn) 2018; 24 (5, Neuroinfectious Disease): 1422-1438
    PubMedGoogle Scholar
  • 37 Marra CM. Other central nervous system infections: cytomegalovirus, Mycobacterium tuberculosis, and Treponema pallidum. In: Brew BJ. ed. Handbook of Clinical Neurology. Vol 152. The Neurology of HIV Infection. Elsevier; 2018: 151-166
    Google Scholar
  • 38 WHO. Guidelines for treatment of drug-susceptible tuberculosis and patient care (2017 update). Accessed February 18, 2020 at: http://www.who.int/tb/publications/2017/dstb_guidance_2017/en/
    PubMedGoogle Scholar
  • 39 Wiggins III RH, Harnsberger HR, Salzman KL, Shelton C, Kertesz TR, Glastonbury CM. The many faces of facial nerve schwannoma. AJNR Am J Neuroradiol 2006; 27 (03) 694-699
    PubMedGoogle Scholar
  • 40 Wierzbicka M, Kopeć T, Szyfter W, Kereiakes T, Bem G. The presence of facial nerve weakness on diagnosis of a parotid gland malignant process. Eur Arch Otorhinolaryngol 2012; 269 (04) 1177-1182
    CrossrefPubMedGoogle Scholar
  • 41 Doets AY, Verboon C, van den Berg B. et al; IGOS Consortium. Regional variation of Guillain-Barré syndrome. Brain 2018; 141 (10) 2866-2877
    CrossrefPubMedGoogle Scholar
  • 42 Yuki N, Hartung H-P. Guillain-Barré syndrome. N Engl J Med 2012; 366 (24) 2294-2304
    CrossrefPubMedGoogle Scholar
  • 43 Leonhard SE, Mandarakas MR, Gondim FAA. et al. Diagnosis and management of Guillain-Barré syndrome in ten steps. Nat Rev Neurol 2019; 15 (11) 671-683
    CrossrefPubMedGoogle Scholar
  • 44 Willison HJ, Jacobs BC, van Doorn PA. Guillain-Barré syndrome. Lancet 2016; 388 (10045): 717-727
    CrossrefPubMedGoogle Scholar
  • 45 Fisher M. An unusual variant of acute idiopathic polyneuritis (syndrome of ophthalmoplegia, ataxia and areflexia). N Engl J Med 1956; 255 (02) 57-65
    CrossrefPubMedGoogle Scholar
  • 46 Al Othman B, Raabe J, Kini A, Lee AG. Update: the Miller Fisher variants of Guillain-Barré syndrome. Curr Opin Ophthalmol 2019; 30 (06) 462-466
    CrossrefPubMedGoogle Scholar
  • 47 Wakerley BR, Uncini A, Yuki N. GBS Classification Group. Guillain-Barré and Miller Fisher syndromes--new diagnostic classification. Nat Rev Neurol 2014; 10 (09) 537-544
    CrossrefPubMedGoogle Scholar
  • 48 Tavee JO, Stern BJ. Neurosarcoidosis. Continuum (Minneap Minn) 2014; 20 (3 Neurology of Systemic Disease): 545-559
    PubMedGoogle Scholar
  • 49 Stern BJ, Royal III W, Gelfand JM. et al. Definition and consensus diagnostic criteria for neurosarcoidosis: from the Neurosarcoidosis Consortium Consensus Group. JAMA Neurol 2018; 75 (12) 1546-1553
    CrossrefPubMedGoogle Scholar
  • 50 Gordin E, Lee TS, Ducic Y, Arnaoutakis D. Facial nerve trauma: evaluation and considerations in management. Craniomaxillofac Trauma Reconstr 2015; 8 (01) 1-13
    CrossrefPubMedGoogle Scholar
  • 51 Ah-See KL, Shakeel M, Maini SK, Hussain SSM. Facial paralysis during air travel: case series and literature review. J Laryngol Otol 2012; 126 (10) 1063-1065
    CrossrefPubMedGoogle Scholar
  • 52 Picciolini O, Porro M, Cattaneo E. et al. Moebius syndrome: clinical features, diagnosis, management and early intervention. Ital J Pediatr 2016; 42 (01) 56
    CrossrefPubMedGoogle Scholar
  • 53 Oh TS, Min K, Song SY, Choi JW, Koh KS. Upper eyelid platinum weight placement for the treatment of paralytic lagophthalmos: a new plane between the inner septum and the levator aponeurosis. Arch Plast Surg 2018; 45 (03) 222-228
    Article in Thieme ConnectPubMedGoogle Scholar
  • 54 Novak CB. Rehabilitation strategies for facial nerve injuries. Semin Plast Surg 2004; 18 (01) 47-52
    Article in Thieme ConnectPubMedGoogle Scholar
  • 55 Tuncay F, Borman P, Taşer B, Ünlü İ, Samim E. Role of electrical stimulation added to conventional therapy in patients with idiopathic facial (Bell) palsy. Am J Phys Med Rehabil 2015; 94 (03) 222-228
    CrossrefPubMedGoogle Scholar
  • 56 Mehta RP, Hadlock TA. Botulinum toxin and quality of life in patients with facial paralysis. Arch Facial Plast Surg 2008; 10 (02) 84-87
    CrossrefPubMedGoogle Scholar
  • 57 Mehta RP. Surgical treatment of facial paralysis. Clin Exp Otorhinolaryngol 2009; 2 (01) 1-5
    CrossrefPubMedGoogle Scholar