HSC Section 3 - Trauma, Critical Care and Sleep Medicine

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with varying degrees of hemifacial paresis. Recovery of facial tone and movement oc- curs within 4 months; severe cases may see ongoing changes in facial function for a period of 12 to 18 months following onset. Approximately 70% of patients will fully recover, whereas the remainder will demonstrate varying degrees of aberrant regen- eration with facial synkinesis. Zoster-associated FP is more prevalent in the older age group and may take longer to recover with a higher percentage of postrecovery resid- ual weakness and synkinesis. The physician should note the patient’s age, ethnicity, and geographic location. A complete head and neck examination should be performed, including a complete cra- nial nerve examination. The facial nerve function on the paralyzed side should be compared with that of the nonparalyzed side of the face. An ear examination together with tuning fork evaluation can rule out otologic causes. Palpation of the parotid area and skin will rule out parotid masses. A fissured tongue may suggest a diagnosis of Melkersson-Rosenthal syndrome (recurrent facial palsy, fissured tongue, recurrent orofacial edema, typically asynchronous). The skin examination may show a rash, nodules (systemic, autoimmune, Lyme, skin cancer) or vesicles (zoster). A directed cranial nerve examination also gives information about any other related nerve deficit and other systemic, infectious, or neoplastic causes. The face is evaluated in horizontal thirds and compared with the nonparalytic side ( Fig. 2 ). In the upper third, one notes the presence or absence of forehead wrinkles and the position of the eyebrow. Symmetry of the upper third may indicate a central cause of FP and the need for further imaging to rule out a central cause. Care must be taken to evaluate the eye and periocular complex. One evaluates eye closure and corneal reflex, as well as the presence of a Bell phenomenon (protective superior rotation of the globe). Schirmer tear test evaluates the viability of the tear film and its ability to keep the eye moist. The vertical height of the medial palpebral fissure will be increased in flaccid paralysis. The position of the lower eyelid relative to the iris PHYSICAL EXAMINATION

Fig. 2. Physical evaluation of patient with acute FP. Horizontal zonal approach to the para- lyzed face. Note the horizontal thirds and comparison of left and right face. In upper zone, note left ptotic eyebrow, retracted upper eyelid, and lower lid ectropion. In the midface, the nasolabial fold is effaced with ptosis of the malar fat pad and inferomedial alar rotation, ptosis of the oral commissure. Lower face shows lack of lower lip depressor and platysma function.

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