Case presentationDr. Samten Dorji
Chief complaint
• A 27 year old woman presented to the eye OPD clinic with weakness in left side of face for 2 weeks duration
She is a monk from Punakha dzongkhag
History of chief complaint
• 2 weeks back she had a sudden onset of left side facial weakness and pain in the left ear which lasted for first three days
• She had difficulty in closing her left eye and had on and off watery discharge. She complains of mild drooling.
• No previous episode• There was no history of trauma
History cont.
• Systemic review• Past ocular history/ocular
medications/systemic medications/ comorbidities/allergies/family history
Examination
• Asymmetry of the face• Absent wrinkling of left forehead• Inability to close left eye(lagophthalmus)• Mouth deviated to the right side• Unable to puff out left cheek
Right eye Left eyeVisual acuity 6/6 6/6
With pinhole
Color vision Normal Normal
Extraocular movements Normal Normal
Bell’s phenomenon Present
Lids and adnexa Normal Normal
Schirmer’s test 15mm 15mm
Conjunctiva and sclera normal normal
Cornea clear Clear( sensation intact)
Anterior chamber Normal depth and quiet Normal depth and quiet
Iris and lens Normal Normal
Pupil Round regular and reactive
Round regular and reactive
Dilated fundus Vessel sheathing and healed scars
Normal
Case summary
• A 27 year old female presented with weakness in left side of face for 2 weeks with difficulty in closing the left eye and left earache for initial 3 days.neurological examination showed left lower motor neuron seventh nerve palsy. Bell’s phenomenon and corneal sensation was intact. Dilated funduscopy showed vessel sheathing and healed scars in the left fundus.
Problems
• Left lower motor neuron seventh nerve palsy
• Healed right retinal vasculitis
Diagnosis
• House-Brackmann grade 3 left lower motor neuron facial nerve palsy with idiopathic cause.
Differential diagnosis
• Infection • Neoplasm• Congenital • Trauma
Investigation
Management
Corticosteroids
•Oral prednisolone 60mg daily for 7 days and tapered until 5mg daily•Anti acid medications•Early treatment is recommended especially within 3 days of symptoms of onset.•Significantly reduced mild and moderate sequelae.
Facial physiotherapy•To help in recovery of facial nerve function•Prevents muscle atrophy and aids in full recovery if prognosis is good
Eye lubricants•To prevent exposure keratopathy•Depending upon the severity of keratopathy the frequency of lubricants is prescribed
ENT review•Assessement was normal•To rule out any pathology causing facial nerve palsy
Lower motor neuron facial nerve palsy
Outline
• Introduction• Anatomy• Aetiology• Clinical evaluation• Management
Introduction
Function Psychology Emotion
Anatomy • Motor fibers that innervate the facial
muscles• Parasympathetic fibers innervating
lacrimal, submandibular, and sublingual salivary glands
• Afferent fibers from taste receptors from the anterior two thirds of the tongue
• Somatic afferents from the external auditory canal and pinna
• The nerve arises from two roots from the pontomedullary junction and enters the internal auditory meatus
•The facial (fallopian) canal= 33 mm •labyrinthine, tympanic, and mastoid•Narrowest in the labyrinthine segment (average 0.68 mm in diameter)
•Facial nerve emerge at the stylomastoid foramen and pass through the parotid gland•These fibers divide into five groups of nerves between the deep and superficial lobes of the gland
Aetiology
• Idiopathic (Bell’s palsy)• Trauma• Infection• Neoplasms • Congenital• Miscellaneous
Bell’s palsy• Acute peripheral facial nerve palsy of unknown cause• Diagnosis of exclusion
Epidemiology
•The annual incidence rate =13 and 34 cases per 100,000 population•Age=15-45 years age group•No race, geographic, or gender predilection•Risk is three times greater during pregnancy
Pathophysiology
• Herpes simplex virus activation is the likely cause of Bell's palsy in most cases
• Inflammatory and possibly infectious cause
• Nerve damage is maximal in the labyrinthine part of the facial canal
Trauma
• Second most common cause• Most common is temporal bone
fractures(blunt and penetrating)• Iatrogenic
Infection
• Varicella zoster virus• Lyme disease• Tuberculosis• Polio• Mumps• leprosy
Ramsay hunt syndrome
•Geniculate ganglionitis•Zoster vesicles in external auditory canal or tympanic membrane(classic sign)
Neoplasms
Congenital
Moebius syndrome
Digeorge syndrome
ColobomaHeart defectsAtresia ofchoanaeRetardation of growthGenital abnormalitiesEar abnormalities
Miscellaneous
• Diabetes mellitus• Hypertension• Amyloidosis• Sarcoidosis• Multiple sclerosis• Guillain-Barre syndrome• Myasthenia gravis• Stroke
Clinical evaluation
Laboratory investigation
• VDRL screening• Imaging studies
Management
• Medical • Surgical
Risk factors for exposure keratopathy
•Absence of corneal sensation•Severe lagophthalmus•Absent bell’s phenomenon•Dry eye
Medical
Avoid ocular irritants
Spectacle side shields
Botulinum injection into levator muscle
•Cyanoacrylate glue•High dose of oral corticosteroids
External eyelid weights
Surgical treatment
• Management of corneal exposure• Correction of lower eyelid ectropion• Management of brow ptosis• Management of chronic epiphora
Management of corneal exposure
Mullerectomy and levator aponeurosis
recession
Silicone punctal plugs Temporary suture tarsorrhaphy
Lateral tarsorrhaphy
Medial canthoplasty Gold weight implant
Correction of lower eyelid ectropion
Skin graft procedure
Mid face lift
Lateral tarsal strip procedure
Management of brow ptosis
blepharoplasty
•Impairment of superior visual field•Cosmetic deformity•Pseudo- blepharoptosis
Management of chronic epiphora
Dry eye
•eye lubricants
Paralytic ectropion
•Lateral eyelid tarsal strip procedure•Dacryocystorhinostomy and jones tube insertion
Hypersecretion/aberrant innervation
• Crocodile tear syndrome(bogoraud’s syndrome)
• Transconjunctival intraglandular Botulinum toxin A injections
Summary
• Introduction• Anatomy• Aetiology• Clinical evaluation• Management
Take home message
• Facial paralysis can be difficult to manage• Should exclude other causes before
labelling it as idiopathic• Multidisciplinary approach• Ophthalmologist role: eye protection and
aesthetic improvement
Thank you