Facial paralysis occurs when there is loss of facial movement. Some are present at birth (congenital), while others occur later in life. Facial palsy can be unilateral (affecting one side of the face) or bilateral (affecting both sides).
For pediatric cases, management is done through a multidisciplinary team approach with an initial consultation done by a pediatric plastic surgeon.
The physical consequences of facial paralysis may include:
- Eye difficulties due to increased eye exposure. Eye irritation, excess tearing, blurred vision, corneal ulcers, and repeated infections may occur.
- The affected eye may have a larger or staring appearance.
- The affected portion of the face may droop, although this is less common in children.
- The nose may be partially collapsed on the affected side, making nasal breathing more difficult.
- In cases of paralysis on one side of the face (unilateral), the mouth is more crooked with smiling. The normal muscles pull the lips to the normal side with smiling.
- In cases where both sides of the face are affected (bilateral), the lips may not move at all.
- The affected lips have poor movement and support, which can result in difficulties with speech
There are many causes of facial paralysis (over 100), but most are due infection/inflammation, trauma, stroke, or tumors.
|Testing and Diagnosis|
Certain tests are sometimes helpful in diagnosing the cause of facial paralysis or predicting whether it will improve. The role for testing varies on an individual basis. Electroneurography (ENOG): ENOG records a muscle signal after maximal stimulus of the facial nerve near the base of the ear. ENOG is useful early after the onset of facial paralysis to predict which patients will have poor recovery of facial movement.
Electromyography (EMG): EMG may be useful in determining the extent of nerve injury and the potential for spontaneous recovery. EMG may also be used to identify appropriate donor nerves in cases of multi-nerve dysfunction. EMG is most useful after 3 months from the time of onset of facial paralysis.
Magnetic Resonance Imaging (MRI): Imaging studies may be indicated to visualize the path of the facial nerve in some cases.
Facial palsy is a complex condition and there is a wide spectrum of therapies. Consideration is given to the cause and duration of the facial paralysis, potential for improvement, the overall health of the child, and the desires of the child and his or her family. Treatment is tailored specifically for the individual child. Management of facial paralysis may or may not involve surgery. In cases of new onset facial paralysis, a course of steroids and anti-viral medication may be indicated. Today, there are many modalities available to assist with facial paralysis. Physical therapy, massage, and chemodenervation (botulinum toxin) may provide benefit in certain scenarios, either alone or in combination with surgery.
For all patients, great care must be taken to protect the eye from increased exposure due to poor eyelid movement. Lubricating drops and ointment are frequently used, and sometimes more protective techniques are employed. Surgery may be necessary for eye protection alone in certain circumstances.
The cause and duration of loss of facial movement is important to determine the optimal method of reconstruction. When facial paralysis has been present since birth (congenital), the facial nerve and facial muscles may not have developed appropriately or may be absent. Attempting to provide a new nerve source to these muscles, then, is not logical or possible, but other types of reconstruction are possible. In cases related to an injury, the facial nerve and muscles may be present and of normal structure, just not in continuity.
After a muscle loses its nerve supply (from any cause), there is a critical window of about 12-24 months to supply a nerve source to that muscle. After this window of opportunity, the muscle is not able to accept a nerve. In these conditions, a nerve supply as well as new muscle must be provided.
Many modalities may be used for reconstruction and these may vary by region of the face.