Contents
What is a lesion of the facial nerve?
Facial nerve lesions – a pathology common in otolaryngology, maxillofacial surgery, sometimes evidence of infections.
Pathological conduction damage, according to medical statistics, is:
unilateral in nature – 94% in patients with a problem of the facial nerve;
bilateral nature – 6% in patients with similar causes.
Predominantly unilateral damage to the facial nerve is a feature of a peculiar (characteristic for the VII-pair) innervation of the nucleus of the facial nerve. The most vulnerable segment of the facial nerve is located in the narrow facial canal of the temporal bone. The facial nerve fills the diameter of the space of this canal by 70%. The disease in this area can occur as a result of even a small edema that compresses the nerve.
Signs of diseases of the facial nerve always appear:
motor disorders, in the form of changes in the motor activity of the muscles of the maxillofacial zone (paresis and paralysis of facial muscles);
sensory disturbances, in the form of changes (increased, decreased) sensitivity of the skin and muscles of the maxillofacial zone in the form of a decrease or increase in the pain threshold;
secretory disorders of the lacrimal and salivary glands;
internal pain (neuralgia – pain along the nerve), not to be confused with sensitivity to external pain
The main indication of a violation of the facial nerve is paresis, and in severe cases, paralysis of the facial muscles, their symptoms and caused disorders of the body systems are detected in all diseases of this nerve.
Paresis of the facial nerve
A partial decrease in motor activity (voluntary movements) of facial muscles is called paresis, in some cases the term prosoparesis is used to refer to it.
Mild paresis is manifested by minor changes in facial expressions during conversation, severe paresis is manifested by a mask-like face, severe difficulty in performing simple actions (puffing out the cheeks, closing the eyes, etc.).
Paresis of any depth always implies only a partial dysfunction of the muscles. This is the most important difference from paralysis. Several options have been proposed for determining the depth of involvement in the pathogenesis of facial muscles and, accordingly, the depth of prosoparesis.
Most often, in the available literature, the variant of determining the degree of functional ability of facial muscles in case of disorders of the VII-pair of cranial nerves, proposed by the American otolaryngologists House WF, Brackmann DE (1985), is mentioned. In 2009, they improved the scale for determining paresis of the facial nerve.
Six-point system for determining paresis of the facial nerve according to Haus-Brackmann (1985)
Norm (1 degree)
Facial symmetry corresponds to the morphophysiological features of the individual. There are no deviations in the functions of facial muscles at rest and during voluntary movements, pathological involuntary movements are excluded.
Mild paresis (grade 2)
At rest, the face is symmetrical. Voluntary movements:
the skin of the forehead is going into a fold;
moderate effort when closing the eyes;
asymmetry of the mouth during a conversation.
Moderate paresis (grade 3)
At rest, slight asymmetry of the face. Voluntary movements:
forehead skin, moderate;
eyes, closed completely with difficulty;
mouth, slight weakness with effort.
Medium paresis (grade 4)
At rest, there is obvious asymmetry of the face and reduced muscle tone. Voluntary movements:
forehead skin motionless;
eyes cannot be closed completely;
mouth, asymmetry, movement with difficulty.
Severe paresis (grade 5)
At rest, a deep degree of asymmetry of the face. Voluntary movements:
skin forehead, motionless;
the eyes do not close completely, when closing the pupil rises;
the mouth is asymmetrical, motionless.
Total paralysis (6th degree)
At rest, the patient has a motionless, mask-like face (usually one half). Arbitrary movements of the skin of the forehead, mouth, eyes are absent.
In some cases, paresis is accompanied by pathological synkinesis – friendly voluntary and involuntary movements of different muscle groups, for example:
drooping of the eyelid is accompanied by raising the corner of the mouth (eyelid-labial synkinesis);
drooping of the eyelids is accompanied by wrinkling of the forehead (eyelid-frontal synkinesis);
squinting of the eyes is accompanied by tension of the neck muscles (eyelid-platysmal synkinesis);
winking is accompanied by tension of the wing of the nose of the same side (Guyet synkinesis);
Symptoms of paresis of the facial nerve
Partial impairment of the motor function of the facial nerve in the corticonuclear fibers of the cerebral cortex is central paresis.
Central paresis VII – pairs of cranial nerves
They occur with lesions of the corticonuclear fibers. The consequence of damage in the cerebral cortex – supranuclear paresis, have characteristic signs, a violation (of varying degrees) of the motor activity of the muscles of the maxillofacial zone, which present with symptoms such as:
paresis (weak mobility) of the tongue, develops on the opposite side of the damage to the cerebral cortex simultaneously with hemiparesis of the muscles (paresis of half of the body);
paresis of facial muscles of the lower part of the face, muscles of the upper part of the face;
all muscles of the face and body on the right or left side.
With minor damage, facial asymmetry disappears during emotions. The muscles of the face involuntarily contract rhythmically (tic).
Damage to the nerve fibers of the facial nerve in the peripheral part with a partial loss of motor activity is peripheral paresis.
Peripheral paresis VII – a pair of cranial nerves
There are several types of damage along the bundles of the facial nerve (after the nucleus of the nerve, in the canal of the pyramid of the temporal bone, tissues of the maxillofacial zone).
Peripheral lesions of the facial nerve are manifested by symptoms:
asymmetry of the facial muscles with a sharp increase during emotions, the absence of the nasolabial and frontal folds, a mask-like face on the affected side;
decrease in muscle tone of half of the face;
a decrease in the corneal reflex – closing the cornea, conjunctival reflex – closing the conjunctiva, superciliary reflex (Bekhterev) – closing the eyes in response to their irritation;
Bell’s symptom or “hare’s eye” symptom, when you try to close the eye, his apple moves up, the palpebral fissure does not close;
the inability to wrinkle the forehead, close the eyes on the side of the lesion, other simple facial actions;
half of the face on the side of the lesion is inactive;
when opening the mouth, the affected half remains inactive;
liquid food, saliva flows from the corner of the lips of the affected side;
possible pain in the ear and face (evidence of involvement in the pathogenesis of the V pair, passing next to the facial nerve in the fallopian canal.
Central and peripheral lesions do not always present with symptoms on the same side of the body or face. Sometimes it happens the other way around: true nerve damage on the left side, and symptoms indicating damage on the opposite side.
Topical symptoms describe the involvement in the pathogenesis of specific sections of the facial nerve located on different segments of the nerve path (from the brain to the terminal neurons – axons or dendrites).
Alternating (alternating) Miyyar-Gubler syndrome
This syndrome is evidence of damage to the nucleus of the facial nerve at the level of the trunk and fibers of the pyramidal tract, which manifests itself:
on the side of the lesion – paresis of the facial nerve;
on the opposite side – hemiparesis (paresis of half of the body), hemiplegia (paralysis of half of the body).
Fauville’s alternating syndrome
Fauville’s alternating syndrome is evidence of involvement in the pathogenesis of the pyramidal tract of the facial nerve and the abducens nerve (VI pair), which manifests itself:
on the side of the lesion, paresis (paralysis) of the abducens nerve (that is, the pupils of the patient are turned towards the lesion);
paralysis of the facial nerve (facial asymmetry).
Involvement in the pathogenesis of the facial nerve root, manifested:
paralysis of mimic muscles;
a symptom of the defeat of the V pair
a symptom of the defeat of the VI pair
a symptom of the defeat of the VIII pair
The pathogenesis of the facial nerve above the branch of the large stony nerve, manifests itself:
hypofunction of the lacrimal gland;
dry eyes.
The pathogenesis of the facial nerve below the place of origin of the large stony nerve, manifests itself:
hyperfunction of the lacrimal gland (lacrimation);
hyperacusis (increased sensitivity to sounds);
hypofunction of the salivary glands (submandibular and sublingual);
paralysis of the mimic muscles on the same (ipsilateral) side of the lesion of the facial nerve.
The pathogenesis of the facial nerve at a level above the place of discharge of the tympanic string appears as:
paralysis of mimic muscles;
lacrimation;
taste disorders.
The pathogenesis of the facial nerve below the place where the tympanic string originates, manifests itself as:
movement disorders;
paralysis of mimic muscles;
lacrimation.
Causes of paresis of the facial nerve
The multiple etiology of the causes of paresis against the background of a single development of pathogenesis has been proven.
The most common causes of paresis of the facial nerve:
mechanical damage or rupture of fibers;
nerve compression resulting in:
infectious, catarrhal or post-traumatic inflammation;
neurinoma (benign tumor of the vestibulocochlear nerve of the VIII pair of cranial nerves), located next to the facial nerve in the temporal canal;
toxic (diabetes mellitus);
ischemia, stroke of cerebral vessels;
idiopathic (of unknown etiology);
medication (blockade of the facial nerve with novocaine or its analogues used for conduction anesthesia, in dentistry, otolaryngology, surgery).
Medical interruption of sensitivity is not a pathological cause of the effect on the nerve pathways. Blockades are used in the pathogenetic therapy of certain stages (pain symptoms) of neuritis.
Complete paralysis of the facial nerve
The total absence of voluntary motor activity of facial muscles on one or two sides of the head is called complete paralysis of the facial nerve. Unlike paresis, the signs of the disease are more obvious. Paralysis is often a consequence of the invasive development of paresis. Therefore, central and peripheral disturbances in the conduction of the facial nerve largely coincide with the already described conditions in paresis. Paralysis differs only in a greater depth of lesions in comparison with paresis.
Symptoms of facial paralysis
The severity of symptoms depends on the number of nerve branches involved in the pathological process. Signs of facial paralysis:
facial asymmetry;
inability to close the eyes;
lacrimation or lack of tear fluid;
problems with eating and swallowing saliva;
the impossibility of pronouncing some letters, syllables.
Symptoms of total paralysis of the facial nerve, determined by physical methods:
mask-like (sullen) facial expression, ptosis of the corner of the mouth, eyelids, eyebrows on one side;
not expressed nasolabial fold, horizontal folds of the forehead;
the wing of the nose is shifted down, and the tip of the nose is shifted to the opposite side of the face from the lesion;
cheek thickening, muscle turgor is absent, the skin texture is pasty, sagging;
gaping palpebral fissure, most of the eye is occupied by the sclera.
Causes of facial paralysis
Among the factors leading to total paralysis include:
extensive damage to the facial nerve;
proximal damage to the facial nerve – perverted perception of sounds, dry eyes;
prolonged (more than three weeks) pain syndrome in the area of the mastoid process;
the development of pathology in persons of the older age group;
the presence of concomitant diseases in the patient (hypertension, diabetes, viral neurotropic diseases), as well as special physiological conditions (pregnancy).
diseases of the facial nerve at the level of axons (determined by electrophysiological studies).
Neuropathy of the facial nerve
The combined name of a group of diseases of the facial nerve, different nosological groups and etiopathogenesis, accompanied by a violation of the motor, sensory functions of the tissues of the maxillofacial zone, manifested by paresis, paralysis, pain, impaired sensitivity on one or both sides of the face.
Neuropathy, have a negative impact on the quality of life of the patient, manifest as a combination of the previously indicated symptoms:
Paresis and paralysis:
give the face asymmetry, violate facial expressions, a person is embarrassed by this state, experiences can self-isolate the patient, take extreme forms;
manifested by the difficulty or inability of the patient to perform simple actions (movements of the eyes, eyebrows, nose, skin of the cheeks and forehead, and others) of the right and / or left sides of the face, also cause feelings in a previously healthy person;
Pain (neuralgia) and sensory disturbances in case of damage to the VII pair of cranial nerves stimulate neuroses, dull attention, and change the patient’s behavior.
Violation of the secretory functions of the glands provoke diseases of the organs (eyes, digestion), for which their secrets play an important role.
Damage to the facial nerve is accompanied by loss of taste, taste (sweet, salty, bitter) is not felt.
Numerous symptoms and signs of neuropathies of the facial nerve, or rather its different departments, are described by the subjective sensations of the patient, by simple physical research methods. For differential diagnosis, methods are used: computed tomography (CT), magnetic resonance imaging (MRI), electromyography, serological methods with the exclusion of infectious diseases, and other methods. The doctor is required to know the topography of the nerve pathways, the patterns of responses of nervous reactions during irritations of different parts of the facial nerve. From the patient – a clear description of the sensations.
Symptoms of neuropathy of the facial nerve
Paresis (paralysis), various changes in sensitivity, pain and other symptoms characteristic of lesions of the facial nerve are common to all diseases of the facial nerve.
Bella’s paralysis or neuritis of the facial nerve
The disease is manifested by paralysis of the facial nerve. The reasons are unknown. Considered idiopathic neuritis.
Bell’s palsy symptoms:
weakness, which develops within two days to a maximum;
pain behind the ear;
lack of taste perception of food;
increased sensitivity to sounds – hyperacusis;
in the spinal punctate, there are abnormally many lymphocytes – pleocytosis;
Paresis that develops within the first week without progressing to paralysis is a sign of a favorable outcome.
Inflammation of the knee joint
The knee is a bend with a thickening of the facial (fallopian canal). The facial nerve passes through the canal for about 40 mm, occupies up to 70% of its diameter. Causes of inflammation of the node of the facial nerve:
herpes zoster;
cooling;
allergies;
inflammation.
Symptoms of inflammation of the knee node (synonyms – ganglionitis (neuralgia) of the knee nodes) appear as:
pain in the ear, radiating to the back of the head, face, neck;
herpetic eruptions (Hunt’s syndrome) in the area of the tympanic membrane, auricle, other localization of the tonsil, face, head;
hyperesthesia (increased sensitivity to sounds);
hearing loss, ringing in the ears;
nystagmus (involuntary rhythmic eye movements in a horizontal or vertical direction);
dizziness;
taste disorders;
lacrimation.
The disease lasts for several weeks, the prognosis is favorable, relapses are rare. Possible relapses are due to the lifelong localization of the herpes virus in the nervous tissue and their periodic activation.
Rossolimo-Melkersson syndrome
The causes of the disease are not fully understood, hypotheses of the causes:
sarcoidosis is a systemic lesion of many organs and tissues with the formation of granulomas;
influenza infection;
sore throats;
injuries (cracks) of the red border of the lips;
drug intoxication;
lichen simplex;
functional disorders of peripheral and central fibers of cranial nerves
Symptoms of Rossolimo-Melkersson Syndrome:
recurrent paresis of the facial nerve and facial muscles, smoothness of the nasolabial fold;
edema (swelling) of the lips, accompanied by the phenomenon of paresis, sometimes the face in the form of a “lion’s mask”;
folded tongue, reminiscent of the folding of the scrotum of a man, therefore another name is “scrotal tongue” from scrotum (scrotum);
granulomatous cheilitis – granulomatous (autoimmune) inflammation of the red border of the lips;
migraine-like pain;
neuritis of the facial nerve;
glossitis – inflammation of the tongue.
The disease occurs in both sexes from adolescence (from 17 years) of life to maturity (up to 60 years), characterized by long periods of illness. Periods of exacerbations and remissions are characteristic.
Clonic hemifacial spasm
For a long time, the causes of the disease were unknown. Currently proven are:
compression of the facial nerve by an adjacent artery or vein (neurovascular conflict) is a primary hemifacial spasm;
tumors, aneurysms, multiple sclerosis, injuries of the lower jaw, hemangiomas (benign tumor) of the temporal bone, vascular malformations – a defect in the form of a fistula between an artery and a vein) is a secondary hemifacial spasm.
The disease is manifested by a painful contraction of the mimic muscles of the face of the side identical to the affected facial nerve (ipsilateral side is the same side). Symptoms of the disease:
contractions of the circular muscle of the eyes begin rarely, then progress;
due to the frequency of contractions, temporary loss of vision is possible;
spontaneous attacks of hemifacial spasms are characteristic;
contractions of the cheek muscles – an atypical symptom;
symptoms progress during periods of stress, overwork.
The prognosis of the disease depends on the strength of the neurovascular conflict; surgical treatment of the disease and drug therapy are possible.
facial myokymia
Facial myokymia is characterized by constant or transient (periodic with a certain rhythm) contractions of facial muscles, which are the result of lesions of the cortico-nuclear pathways of the facial nerve. The reasons are:
demyelinated plaques;
malignant neoplasms of the brain;
multiple sclerosis.
Symptoms of facial myokymia:
fasciculations – pulsations of facial muscles;
tremor (trembling) of the cheeks.
Causes of neuropathy of the facial nerve
Neuropathy is the result of a variety of causes, obvious and idiopathic (non-obvious). Proven causes of neuropathy of the facial nerve include:
viral, bacterial, fungal infections;
compression of the facial nerve by a tumor or arteries (with hypertension)
malformations of facial vessels;
systemic diseases;
hypothermia of the facial nerve;
pinched nerve in trauma to the temporal bone.
Pinched facial nerve
Pinching of the facial nerve is a partial or complete squeezing of a section of nerve tissue fibers without violating its integrity. There are temporary (chronic) or permanent (acute) infringement.
Symptoms of a pinched facial nerve
Localization of symptoms in adults and children is often different.
Symptoms of infringement of the facial nerve in adults often in the facial canal correspond to:
“tunnel” symptom of idiopathic Bell’s palsy;
inflammation of the knee joint.
clonic hemicephalic spasm.
All of these symptoms are described above in the text.
Symptoms of infringement of the facial nerve in newborns:
on the damaged side, the nasolabial fold is smoothed out, the eyelids do not close;
crying is accompanied by pulling the mouth to the healthy side;
the search reflex is weakened (Kussmaul reflex): stroke the corner of the child’s mouth with your finger, not the lips, in response, opening the mouth and turning the head in the direction of irritation. The reflex will disappear by three months;
other symptoms are possible (their visualization depends on the location of the pinched nerve).
The prognosis for timely treatment is favorable. Delays in diagnosis and treatment are unacceptable.
Causes of pinched facial nerve
Possible causes of pinched facial nerve roots in adults and newborns.
Causes of a pinched nerve in adults:
facial tumors;
pathological growth (scars) of the connective tissues of the face;
spasms of masticatory muscles of the face;
temporal bone injury;
displacement, dislocations, subluxations of the jaw joints;
causes corresponding to nerve lesions in the facial canal and neurovascular conflict in clonic hemicefal spasm.
Causes of a pinched nerve in newborns:
the result of pathological childbirth, with inept obstetric care, is possible with the imposition of forceps (head presentation of the fetus);
the result of physiological childbirth with an abnormally narrow pelvis in primiparas, the unpreparedness of the birth canal, the narrowness of the birth canal.
Stiff facial nerve
Neuralgia of the facial nerve (pain in the region of the nerve pathways). Primarily it is a seasonal (late autumn-winter) pathology. Newborns are most sensitive to zastuzivaniye of a facial nerve. Chronic neuralgia occurs in the off-season, as well as in the summer, after the usual local cooling of the face (washing with cold water, working or visiting industrial refrigerators in summer, and other reasons.
Local cooling of the behind-the-ear region, accompanied by tissue edema in this area. As a result of edema, there is a narrowing (stenosis) of the facial canal through which the nerve passes. As a result of nerve compression, pain (neuralgia) of the facial nerve occurs.
The etiology of hypothermia and infringement of the facial nerve is different, and the pathogenesis and symptoms generally coincide.
Symptoms of congestion of the facial nerve
The main (pathognomonic) and first symptom of neuralgia of the facial nerve is pain in the area of the mastoid process. It is located behind the auricle, palpated (felt) in the form of a tubercle. Pain quickly turns into paresis, in severe cases, into paralysis of facial muscles.
Other symptoms are similar to those of neuropathies (Bell’s syndrome, inflammation of the knee of the facial canal, and others).
Treatment of the facial nerve
In the acute period of neuropathy of the facial nerve, therapeutic measures are indicated to:
enhancing blood and lymph circulation – intramuscular or perineural injections of hormonal preparations of glucocorticoids (prednisolone, dexamethasone and others);
removal of inflammatory edema – diuretics (furosemide and others) and antioxidants (lipoic acid and others);
restoration of the function of facial muscles, prevention of the development of muscle contracture (muscle contraction) – ipidacrine and other drugs cholinesterase inhibitors (neuromidine, amyridine).
During the period of convalescence (recovery) and the chronic course of the disease, therapeutic exercises, massage, physiotherapy, acupuncture, and applications are indicated.
Therapeutic exercises are carried out mainly for the muscles of the healthy side:
dosed tension and relaxation of facial muscles,
facial exercises imitating laughter, sadness, joy and others
articulation training of sounds (vowels, consonants)
Massage of the healthy side and the collar zone (stroking, rubbing, light kneading, vibration).
Physiotherapy – is indicated during the chronic course of neuropathies of the facial nerve:
infrared heat on the affected area (the exposure is determined by the doctor), but not more than 15 minutes per session and not more than 4 times a day. The general course is no more than 10 days.
Ultra-high-frequency exposure (UHF) in the projection of the branching of the facial nerve in front of the tragus (process in front of the ear opposite the ear opening), mastoid process (behind the ear), the area near the outer corner of the eye (crow’s feet area) Exposure is not more than five minutes a day, the total number of procedures is up to twelve.
Low-frequency magnetotherapy, including:
alternating magnetic field (AMF);
pulsed magnetic field (PMF);
running (BeMP);
rotating (VRMP).
UHF therapy on the area behind the ear (mastoid area).
Acupuncture or acupuncture is done by a trained doctor.
All medical manipulations, including medications, have limitations and contraindications. Application is possible only after a thorough examination, obtaining the results of a differential diagnosis, based on the recommendations of a physiotherapist.
With prolonged inflammatory processes of the facial nerve, especially at the onset of contractures (contractions) of the facial muscles, phonophoresis with a glucocorticoid (prednisolone) or detergent (trilon-B), ozocerite, paraffin applications on the affected area of the skin of the face, injections of therapeutic doses of the botulinum toxin preparation are indicated.
In some cases, surgical intervention is effective, for example, with clonic hemifacial spasm.