otolaryngology , facial weakness clinical history

1. Facial weakness
Dr.Khalil Nasr Elkahlout
R3 ENT , Alshifa hospital

2. ‘A 40-year-old man is referred to your clinic with a
history of a unilateral facial weakness for the
last 2 days.’

3. Facial nerve anatomy and pathophysiology
•The facial nerve is derived from the 2nd branchial
arch & contains motor, sensory and parasympathetic
fibers.
• The facial motor nucleus is in the pons.
•The motor branch supplies the muscles of facial
expression, buccinators, stylohyoid, stapedius,
posterior belly of digastrics and platysma.
• The sensory branch carries taste via the chorda
tympani.

5. •The parasympathetic component supplies the secretomotor
function for the submandibular/sublingual salivary glands
and nasal, lacrimal and palatine mucosal glands.
•The nerve is classically divided into four subsections:
a cerebellopontine , internal acoustic meatus, intratemporal
and an extratemporal division.
•Facial nerve weakness is classified on the House–Brackmann
classification of facial nerve palsy (I for normal to VI for no
movement).

6. General structure of the History
•When taking a history it is important to keep
mindful of the anatomy of the nerve.
•This will help you give a logical format and
ensure that possible causes are not forgotten.
•Facial weakness can occur with impairment at
any part of the neuromuscular tract.

7. The most common causes of facial
weakness are:
• Bell’s palsy (idiopathic facial nerve palsy)
•Ramsay Hunt syndrome (herpes zoster oticus)
• neoplasia, e.g. parotid malignancy
• trauma, e.g. birth trauma or skull base fracture
• infection, e.g. AOM/CSOM or Lyme disease
•Congenital
•central nervous system dysfunction, e.g. stroke.
Although the differential diagnosis of a facial nerve weakness is
broad, the history and examination significantly aid in diagnosis.

9. Specific questions
• When did the weakness start?
• What did you first notice?
• Is it just one side or have you noticed changes to the other side?
• Did it come on suddenly or has it been coming on gradually? (The
time course is not always instructive, as all causes can progress at
similar rates.
However, in cases that are not improving after 6 weeks, further
investigation to rule out neoplasia should be undertaken.)

10. •Have you had any changes to your ears?
• (Ask specifically about otalgia, vesicles, hearing loss, vertigo,
tinnitus and discharge.
These are specific questions for associated otological disease.
Possibilities that should be considered include AOM with a
dehiscent facial nerve, malignant OE, cholesteatoma and skull
base neoplasia.)
•Any surgery to the ears?
•Have you had any trauma to your head lately?
(Temporal bone fractures can compromise the nerve.)

11. •Have you been at depth or to high altitude recently?
(Patients with a dehiscent facial nerve canal can present
with facial baroparesis, which tends to be a self- resolving
neuropraxia.)
•Have you noticed any other weaknesses or sensory
disturbances in the rest of the body?
(Other CNS pathology, e.g. multiple sclerosis or stroke,
should always be considered.)

12. Past medical history and general systems review
• Do you have any other conditions?
(Ask specifically about HTN and DM )
• Have you ever had a cancer or tumor diagnosed?
(Metastatic disease from other head and neck primary sites is possible.)
• Any family history of similar occurrences?
Melkersson–Rosenthal syndrome (lip edema, recurrent facial weakness and
fissuring of the tongue) can be hereditary

13. • Drug history
Are you on any medications?
Any allergies to medications?
• Social history
Do you smoke or drink alcohol?
What do you do for work?
Have you been travelling recently?
(For example, to areas where Lyme disease is endemic.)

14. Further discussion: explanation and planning
• Perform a full examination of the facial nerve and grade the
weakness (e.g. using the House–Brackmann scale).
The weakness should be classified into UMN or LMN lesion. Because
of bicortical representation there is forehead sparing in a UMN lesion,
e.g. with CVA , With an LMN palsy, e.g. Bell’s palsy, there will be
weakness in all divisions of the face.
• full examination of the ipsilateral ear and mastoid.
• full cranial nerve examination; check cranial nerve V in particular, as
paraesthesia or pain in this distribution can be a sign of acoustic
neuroma – Hitselberger’s sign.

17. • Plan flexible nasendoscopy, to rule out a nasopharyngeal cancer.
By this stage very likely that other lower cranial nerves will also
compromised.
• full examination of the parotid gland to rule out a parotid tumour.
A parotid mass with facial nerve palsy is suggestive of malignancy, e.g.
mucoepidermoid, adenoid cystic subtypes.
• PTA should be performed to document
the baseline hearing level.

18. Treatment:
• first, educate about eye protection to avoid corneal drying , ulceration and ultimately,
blindness.
• If an obvious cause such as parotid mass then manage this appropriately, e.g. perform
FNA for histology.
• Blood tests, e.g. Lyme disease serology, should only be performed if indicated
from the history.
• In the absence of an obvious diagnosis make an initial diagnosis of Bell’s palsy.
( A 7- to 10- day reducing dose corticosteroid improves prognosis ,
Antivirals not improve recovery )
• Ramsay Hunt syndrome (facial weakness and otic vesicles) is treated with a course of
acyclovir and reducing corticosteroids.

20. Thanks