Neurology: Your Face Looks Funny (?)

I was walking through Target today, and couldn't help myself but overhear a conversation couple people were having. One lady said that her husband's face looked funny couple mornings ago, and his whole right side seemed to be droopy. Afraid that it might be a stroke, they rightfully went to the ER, but luckily he wasn't having a stroke. So that was a relief, but his face still looks "funny"...

There are many things that you should consider when someone's face seems droopy. This occurs often due to some sort of "damage" to cranial nerve 7, or also known as the facial nerve. The damage can happen anywhere along the peripheral section of the nerve (away from the brain, closer to the facial muscles) or can happen in the central section (in the brainstem, right between the pons and medulla). Depending on the section of the nerve that is affected, it is called either "peripheral facial palsy" or "central facial palsy." It is sometimes difficult differentiate between the two without further testing, but clinically the peripheral facial palsy generally presents with drooping of the whole side of the face (including forehead, eye lid, and mouth) and the central facial palsy generally presents with drooping of just the lower half of the face (just the corner of the mouth). This is because the upper part of the face is also innervated by the other side branches of the facial nerve (cranial nerves run in pairs), thus the nerves from the contralateral side compensates for the loss of innervation from the ipsilateral side. As presented by the lady's husband in the story above, he had complete one side facial droopiness, which most likely means he had a peripheral facial palsy. But what caused this to happen?

There are many things that can cause facial nerve palsy. Just to name some, here is a list of differential diagnoses (possible causes) from Medscape:

• Acoustic neuroma and other cerebellopontine angle lesions
• Acute or chronic otitis media
• Amyloidosis
• Aneurysm of vertebral artery, basilar artery, or carotid arteries
• Autoimmune syndromes
• Botulism
• Carcinomatosis
• Carotid disease and stroke - Including embolic phenomenon
• Cholesteatoma of the middle ear
• Congenital malformation
• Facial nerve schwannoma
• Geniculate ganglion infection
• Glomus tumors
• Guillain-Barré syndrome
• Herpes zoster
• Human immunodeficiency virus (HIV) infection
• Leukemia/lymphoma
• Leukemic meningitis
• Malignant otitis externa
• Melkersson-Rosenthal syndrome
• Meningitis
• Mycoplasma pneumonia
• Nasopharyngeal carcinoma
• Osteomyelitis of the skull base
• Otitis media
• Parotid gland disease or tumor
• Pontine lesions
• Sarcoma
• Skull base tumor
• Teratoma
• Tuberculosis
• Viral syndromes
• Wegener granulomatosis
• Wegener vasculitis
• Alcoholic neuropathy
• Anesthesia nerve blocks
• Basal skull fractures
• Barotrauma
• Benign intracranial hypertension
• Birth trauma
• Carbon monoxide exposure
• Diphtheria
• Facial injuries
• Facial trauma (blunt, penetrating, iatrogenic)
• Forceps delivery
• Iatrogenic - As in otologic, neurotologic, skull base, or parotid surgery
• Infectious mononucleosis
• Kawasaki disease
• Leprosy
• Metastatic disease
• Mumps
• Polyneuritis
• Temporal bone fracture
• Tetanus
• Thalidomide exposure
• Toxic

Yes, that was a long list. But that is exactly the point. There are NUMEROUS causes of facial palsy. Are they all common? Of course not. Doctors just love to make a long list when they're not sure what to do. Of these, the most common ones to consider are herpes simplex or zoster virus, stroke, Guillain-Barre Syndrome, acoustic neuroma, and trauma (various kinds). You should also consider Lyme Disease if you live somewhere in the Northeast region of U.S. Moreover, to make things more confusing, they can occur on BOTH sides of the face at the same time! These are very rare, and some possible causes are sarcoidosis, Lyme Disease, Guillain-Barre Syndrome, meningitis, and neurofibromatosis type 2.

For our main character of the story above, luckily it sounded like he had one of the more benign causes of unilateral peripheral facial palsy, or also known as Bell's Palsy. This is usually idiopathic (unknown reason, because we are idiots... just kidding), or it can be due to underlying herpes simplex virus type 1, which about 65 - 90% of people around the world have (often presenting as cold sores), or some other virus that had been living dormant in the facial nerve. Most of these cases go away on their own, and there are no critical sequelae afterwards. Obviously I do not know the whole story behind the above mentioned gentleman's history and I most likely will not know what happens to him later on. If you encounter a similar situation, you should always be aware of the "red flags" and try to figure out if it is an emergency or not. Sometimes that is hard to do, so in that case you should go to the hospital. But, some red flags to look for are: concurrent extremity/limb numbness or paralysis, fever, severe headache, neck stiffness and pain, and history of recent trauma to the head or neck (Carotid artery dissection can lead to a stroke and cause droopiness of upper of the face! We will revisit this topic when we talk about STROKE in the future, and how that may relate to Jiu Jitsu!). If you notice any of those red flags or are just unsure, then make sure to go to the ER. If not, or if you've had it for a while without anything else happening, you can just make an appointment as an outpatient with your primary care doctor. But I always say, when it doubt, just go to the hospital.

I hope this was an interesting/helpful topic. Feel free to ask me any questions!  

=)  <------ no droopiness!

Sources: 

http://emedicine.medscape.com/article/1146903-differential

http://www.mayoclinic.com/health/bells-palsy/DS00168/DSECTION=causes