Information Sheet for Candidates

A 36 year old woman, Jennifer, presents to you

in a GP surgery with a sudden onset of left sided
facial weakness with facial disfigurement and
sudden onset of numbness, a feeling of fullness
and swelling and periauricular pain.
Your task is to:
take a brief focused history
Examine the patient
explain the possible causes and the most
likely diagnosis to the patient
explain treatment options

HISTORY:
These symptoms and in addition a crooked smile, some asymmetric weakness of facial
muscles, including the eyelids, an irritated, dry and tearing eye, drooling from the left
corner of the mouth, have developed over the last 24 hours.
The patient had a viral illness 3 weeks earlier and quite a stressful time over the last two
weeks.
EXAMNIATION:
Patient alert and oriented . Normal vital signs.
Features of facial nerve palsy:
unitlateral droop of the corner of the mouth
flattening of nasolabial fold
crooked smile
pat. has impaired blinking of eyelid, the direct corneal reflex is absent!. When
trying to close the eye lids, the affected upper eye lid does not close and the eye
rolls upwards under the upper eyelid with accentuation of the wry
mouthtriangular deformity (Bell reflex!)
inability to blow the cheek
lack of forehead muscle tone
The palpebral fissure can be wide and the patient might be unable to close his eye. The
patient might have a decreased pinprick sensation behind the ear (Arnold nerve).
DIAGNOSIS:
BELLS PALSY (IDIOPATHIC FACIAL NERVE PARALYSIS)
CAUSES:
Idiopathic (?inflammatory swelling involving the facial nerve in the bony
facial canal, probably of viral nature or following a viral infection)
Herpes
Otitis media
Cholesteatoma
Mastoid infection
Carcinomatous or leukaemic invasion of the nerve
Cerebellopontine angle or glomus jugulare tumors
TREATMENT OPTIONS:
1. patient education and reassurance!!!
2. Methyl cellulose drops for the eye and protection
3. Corticosteroids , e.g. 60 80 mg prednisolone per day
(cave hypertension, diabetes, peptic ulcer disease, tuberculosisi
or immunosuppression)
4. Zovirax if herpes suspected
5. ?Acupuncture
6. Faradic stimulation of the nerve and physical therapy only to
provoke motion and to prevent contractures in paralysed muscles
7. Follow-up to monitor the extent of paralysis and especially the
eye (conjunctivits, corneal ulcerations)

8. If the patient is very anxious consider referral to neurologist for

possibly further investigations like nerve conduction test and CT
head.
ADVICE:
70 80 % OR CASES RECOVER COMPLETELY WITHIN A FEW WEEKS.
???Hitselbergers sign:
Decreased sensation along the external acoustic meatus
Symptoms:
Metallic taste??
DD:
TIA / CVA
GBS
Lyme disease
Sarcoidosis
Collagen vascular disease
Polio
Ramsay Hunt Syndrome (Herpes around the ear)

ANATOMY OF THE FACIAL NERVE The facial nerve is a mixed

nerve, containing (show figure 1):

Fibers for motor output to the facial muscles

Parasympathetic fibers to the lacrimal, submandibular, and sublingual salivary glands

Afferent fibers for taste from the anterior two thirds of the tongue

Somatic afferents from the external auditory canal and pinna

Facial nerve anatomy and histopathology

The facial nerve is a mixed nerve, containing fibers for motor output to the facial
muscles, parasympathetic fibers to the lacrimal, submandibular, and sublingual
salivary glands, afferent fibers for taste from the anterior two thirds of the tongue, and
somatic afferents from the external auditory canal and pinna. Reproduced with
permission from: Jackson, CG, von Doersten, PG. The facial nerve. Current trends in
diagnosis, treatment, and rehabilitation. Med Clin North Am 1999; 83:179. Copyright
1999 Elsevier.
House-Brackmann classification of facial nerve dysfunction
Grade
Characteristics
I. Normal
Normal function in all areas
Gross
Slight weakness noticeable on close inspection
May have slight synkenesis
Normal symmetry and tone at rest
II. Mild dysfunction
Motion
Forehead: Moderate to good function
Eye: Complete closure with minimal effort
Mouth: Slight assymetry
Gross
Obvious but not disfiguring difference between the two sides
Noticeable but not severe synkinesis, contracture, or hemifacial
spasm
Normal symmetry and tone at rest
III. Moderate dysfunction
Motion
Forehead: Slight to moderate movement
Eye: Complete closure with effort
Mouth: Slightly weak with maximum effort
IV. Moderately severe
Gross
dysfunction
Obvious weakness and/or disfiguring asymmetry
Normal symmetry and tone at rest
Motion
Forehead: None
Eye: Incomplete closure

V. Severe dysfunction

VI. Total paralysis

Mouth: Asymmetric with maximum effort

Gross
Only barely perceptible motion
Asymmetry at rest
Motion
Forehead: None
Eye: Incomplete closure
Mouth: Slight movement
No movement