HSC Section 3 - Trauma, Critical Care and Sleep Medicine

Medical Management of Acute Facial Paralysis

and a snap test of the lower eyelid skin will evaluate the elasticity of the lower eyelid skin, which is an indication of the tone of the orbicularis oculi muscle. Advancing age will diminish lower eyelid skin tone and so, comparison with the nonparalyzed side is essential. In the presence of paralysis, the middle third of the face will show flaccid ptosis of the mid cheek and fat pad. The nasal ala may also be displaced inferomedially and the philtrum pulled to the contralateral side. External nasal valve obstruction of the para- lyzed side is often present. The nasolabial fold on the affected side will be effaced. In the lower third, the oral commissure may be inferiorly displaced and there may be weakening of the lower lip with oral incompetence. One should take note of the type of paralysis: completely flaccid, partially flaccid, or a combination of flaccidity and synkinesis. This will be helpful in determining the cause as well as a possible treatment.

DOCUMENTATION

Documentation with photography and videography is performed at the first and rele- vant follow-up visits. Still photographs of prescribed facial expressions are taken to show the range of facial movement. A short video clip of the same expressions is also performed. This allows for ongoing evaluation as the patient recovers or as inter- ventions are performed.

OUTCOME MEASURES

Patient-reported and physician-reported outcome measures are also completed. Patient-reported questionnaires include the FaCE instrument (Facial Clinimetric Eval- uation Scale), FDI (Facial Disability Index), and NOSE instrument (Nasal Obstruction and Septoplasty Effectiveness Scale). Physician-reported scales include the Sunny- brook Facial Grading Scale and the eFACE assessment (electronic clinician-graded facial function scale). These measures are useful in assessing the patients temporally as well as providing a comparison after future interventions. The most common cause of acute FP is BP. 1–4 However, this is always a diagnosis of exclusion and should be given only after all other diagnoses have been entertained (see Table 1 ). BP is named after Sir Charles Bell, who described idiopathic FP. 5 Although Frie- drich 6 first described the disorder 23 years prior, Bell’s name is ascribed to the phe- nomenon. 1,2 BP is by far the most common cause of acute FP and accounts for up to 70% of cases. Depending on the population studied, the second most common etiol- ogy is congenital FP followed by Ramsay Hunt syndrome (RHS). 1 Clinically, patients will experience a viral prodrome with post/auricular pain, ipsilateral tongue numbness, or loss of taste. The FP will progress over 3 days. The incidence of BP has been variously reported to be between 18 and 40 cases per 100,000 persons annually. 1,7 The largest studies with 1000 to 2000 patients show an average incidence of 29 per 100,000. 1,3,8,9 The wide variability is attributed to the various heterogeneous populations and ethnicities studied. Patients 30 to 45 years old are most commonly affected. 8 There is a slight increase in the winter months, 10 but no gender predilection. The etiology of BP is thought to be viral reactivation of latent herpes simplex virus (HSV) 10–15 or varicella zoster virus (VZV) or human herpes virus 6. 16 After primary ETIOLOGY OF ACUTE FACIAL PARALYSIS

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