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Syed A. A. Rizvi*1, PhD., Rudy Lacosse2, PA., Ayman M. Saleh3, PhD., Jasmin Ahmed4,  BS., Jose D. Suarez5, MD., Sultan Ahmed*2, MD.

1College  of  Pharmacy, Nova Southeastern University,  3200 South University Drive,  Fort Lauderdale, FL 33328, USA. 

2JAS Medical Management LLC, 6151 Miramar Pkwy, Miramar, FL 33023, USA. 

3Department of Basic Medical Sciences, College of Medicine, King Saud Bin Abdulaziz University  for Health Sciences, National Guard Health Affairs,  P.O. Box:  3660, Mail  Code: 3127, Riyadh 11481, Saudi Arabia. 

4School  of  Medicine,  Spartan  Health  Science  University,  Laborie,  00124,  St.  Lucia,  West Indies. 

5Larkin Community Hospital, 6161 Sunset Drive, South Miami, FL 33143, USA.

Correspondence: 

Dr.  Syed  A.  A.  Rizvi*1,  College  of  Pharmacy,  Nova  Southeastern  University,  3200  South  University  Drive,  Fort  Lauderdale,  FL  33328,  USA.  954-262-1542.  srizvi@nova.edu 

Dr. Sultan S. Ahmed*2, JAS Medical Management LLC, 6151 Miramar Pkwy, Miramar,  FL 33023. 954-965-6001. cmeahmed@bellsouth.net

History 

A  48-year-old female patient presented with left-sided  facial  paralysis.  She stated, facial weakness started about four years ago with a mild left ear pain. She experiences uncomfortable hearing in her  left ear, particularly in a crowded and noisy place and her taste sensations are not the same as before either. She was unable to close her left eye while trying to sleep and used pillow to keep it covered.  The lagophthalmos and consequent corneal exposure resulted in severe dry eyes and discomfort. Her  past medical history includes hypertension and obesity. The patient denied history of dizziness, facial  trauma,  and  flu-like  illness.  She  is  unemployed  and  her  personal  and  family  histories  were  noncontributory.   

Physical Examination  

Physical exam indicated temperature of 97.70 F; pulse rate 88; blood pressure, 122/78 mmHg, height  67 inches, and weight  190lbs with BMI  29.0. She  has left-side  facial  drooping with  the evidence  of  being unable to close her upper eyelid and mouth, wrinkling of the left side of the forehead, and has  aching  of  the left  ear  with  sensitivity  to  sound.  Tympanic membrane  bilaterally looks  normal. Her  motor activity of left forehead has blunted appearance, including blunted left nasolabial fold. 

Discussion  

Bell’s Palsy is one of the most common  forms of  facial paralysis affecting the seventh cranial nerve.  Weakness  of  the  seventh  cranial  nerve  may  begin  with  symptoms  of  pain  in  the  mastoid  region  affecting normal hearing and producing full or partial paralysis of movement of one side of the face.1,2  Facial nerve paralysis occurs due to the interruption at any of the facial nerve level and may result in  complete  or  partial  paralysis  of  facial  muscles  resulting  in  decreased  salivation,  tearing  disorders,  hyperacusia  and  hypoesthesia  of  external  auditory  canal.3 Patients  with  bell’s  also  commonly  deal  with situation where the upper lid is always up and a drooping lower lid. The eyelids stay open even  as  patient  trying  to  sleep,  resulting  in  prolong  dry  that  can  lead  to  corneal  ulcers,  infection,  perforation and loss of vision. Implantable devices have been used to restore dynamic lid closure in  cases of severe, symptomatic lagophthalmos.4,5 

The anatomical component of the seventh cranial nerve has motor and sensory functions. The motor  allows  for  facial expression, secretion of saliva, and excretion of  tears. The sensory allows  for  taste  and  muscle  proprioception.  The  seventh  nerve  originates in  the  pons  and  is  located  lateral  and  anterior  to  the  abducens  nucleus.  The  nerve  enters  the  internal  auditory  meatus  with  the  vestibulococholear  nerve,  then  forms  the  geniculate  ganglion  where  it  bends  into  the  facial  canal  where it exits the skull through stylomastoid foramen. The nerve finally passes the parotid gland and  subdivides  into  the  temporal,  zygomatic,  buccal,  marginal  mandibular,  and  cervical  of  the  facial  muscles. 

If damage occurs to the facial nerve at the site of the stylomastoid foramen, then paralyzes of all the  facial muscle will occur. In addition, the patient will experience absent of facial creases and skin folds  (especially  on  the  forehead),  decrease  taste  sensation,  drooping  of  the lower eyelid and  depressed  angle of the mouth. 

Signs  during facial examination  may  help  identify  and  pinpoint  lesion  of  the  facial  nerve.  It  is  important to document the location of the lesion to aid in assessment and plan of the patient (table  1).   

Facial Branches with Lesion Signs 

Temporal branch Raise upper eyelid. 

Draw medial eyebrow downwards. 

Produce  transverse  wrinkle  over  the  

bridge of the nose. 

Close eye firmly. 

Vertical wrinkle in  the  forehead  (causing  

frowning). 

Zygomatic Absent nasolabial fold. 

Buccal branch Inability to elevate the upper lip. Compress cheeks, absent nasolabial fold. 

Keep food under pressure while chewing. 

Raised angle of the mouth. 

Mandibular  Inability to close mouth 

Draw lips in and press on teeth 

Protrude  lips,  retracts  and  depress  angle  

of the mouth 

Draws lower lip downward 

Cervical branches Inability  to  raise  and  wrinkle  skin  of  the  neck. 

Table  1: Localization  of  lesions  in  various  branches  of  the  facial  nerve  and  associated  physical  symptoms. 

The  differential  diagnosis  of  Bell’s  palsy  includes  Ramsay  Hunt  Syndrome,  acoustic  neuroma,  and  brainstem glioma. Ramsay Hunt Syndrome is due to reactivation of varicella zoster in the geniculate  ganglion, consists of facial palsy associated with a vesicular eruption, location may be in the pharynx,  and external auditory canal. Patient may present with associated symptoms such as tinnitus, hearing  loss, nausea, vomiting, and vertigo.  Acoustic neuroma, a tumor on the vestibulocochlear nerve, may  cause similar symptoms. Brainstem gliomas may cause similar effects over the 7th nerve.  

Treatment and Management 

The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) and the American  Academy  of  Neurology (AAN)  recently  published  guidelines  for  the  treatment  of  Bell’s  palsy.6-7 The  initial  treatment  of  Bell’s  palsy  is  glucocorticoids  therapy.  Glucocorticoids  steroid  medication  such  as  prednisone  can  be  given  to  shorten  the  recovery  period  and  improve  the  functional outcome. Prednisone 60mg daily for 5 days, then taper down to 10mg for the next 5 days,  with  total  treatment  for  10  days.  Since, there  are  reports  suggesting  possible  connection between  Bell’s  palsy, herpes  simplex  and  varicella  zoster  viruses; antivirals  such  as  acyclovir  could also  be  prescribed. Nonetheless, recent reports indicate, treatment with acyclovir alone or in simultaneously  with prednisolone do not show any advantage and prednisolone alone is as effective.8-10 

Since functions  of facial  nerve  are complex, quite a  number  of  problems  can  arise from prolonged  Bell’s  palsy.  Eye  is  one  of  the  most  sensitive  and  easily  damageable organs due  to  Bell’s  palsy.  Because eyelids are unable to close, this may to lead to dryness and abrasion of the corneal. Artificial  teardrops  should  be applied every  hour  during  the  time  that  the  patient is awake.11 For additional 

eye protection, protective glasses should be prescribed.  The degree of lagophthalmos and the use of  eye lubricants needed may be addressed with surgery (upper lid weighting or tarsorraphy).5 In case  of our patient, her left upper eyelid was loaded with stainless steel weight, allowing her to close her  eyes, thus preventing potential corneal damage and sleep comfortably (Figure 1).

Figure 1

Figure 2

Figure 3

Figure 1. From left to right, the hemifacial paresis of the left upper and lower face, left upper eyelid  with pretarsal stainless weight implantation.

References: 

1. Adour KK. Current concepts in neurology: diagnosis and management of facial paralysis. The New  England Journal of Medicine. 1982;307:348151. 

2. Valença MM, Valença LP, Lima MC. Idiopathic facial paralysis (Bell's palsy): a study of 180 patients  [Paralisia facial periférica idiopática de Bell]. Arquivos de Neuro-Psiquiatria. 2001;59:733-739. 

3.  Ahmad  SJ,  Rather  AH.  A  Prospective  Study  of  Physical  Therapy  in  Facial  Nerve  Paralysis:  Experience at a Multispeciality Hospital of Kashmir. Journal of Medical Sciences. 2012;15(2):145-148 

4. Lee V, Currie Z, Collin JRO. Ophthalmic management of facial nerve palsy. Eye. 2004;18:1225-1234.

5.  Rahman  I,  Sadiq  SA.  Ophthalmic  management  of  facial  nerve  palsy:  a  review.  Surv  Ophthalmol.  2007; 52(2):121-44. 

6. Baugh RF, Basura GJ,  Ishii LE, et al. Clinical practice guideline Bell’s palsy. Otolaryngol Head Neck  Surg 2013;149(3 Suppl):S1–27. 

7.  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;79:2209-2213. 

8.  Sullivan  FM,  Swan  IR,  Donnan  PT  et al.  Early  treatment  with  prednisolone  or  acyclovir in  Bell’s  palsy. New England Journal of Medicine 2007;357(16):1598-1607.  

9. Goudakos JK, Markou KD; Corticosteroids vs corticosteroids plus antiviral agents in the treatment  of  Bell palsy:  a  systematic  review  and  meta-analysis.  Arch  Otolaryngol  Head  Neck  Surg.  2009;135(6):558-564 

10.  Sullivan FM,  Swan  IR,  Donnan  PT,  Morrison  JM,  Smith  BH,  McKinstry  B,  et  al.  A  randomised  controlled trial of the use of aciclovir and/or prednisolone for the early treatment of Bell’s palsy: the  BELLS study. Health Technol Assess. 2009;13(47):iii-iv, ix-xi 1-130. 

11. Holland NJ, Weiner GM. Recent developments in Bell's palsy. BMJ 2004; 329(7465):553-557.