An Unusual Cause of Facial Palsy That Originally Had Been Diagnosed As Bell’s Palsy

Introduction

Patient JRK presented with reduced range of movement and moderate synkinesis on the left side of his face, onset September 2005. The facial palsy had originally been diagnosed as Bell’s Palsy, but MRI scan showed a pituitary tumour which was felt to be compromising the Facial Nerve. The tumour was treated with medication which brought about a large reduction in size, but there was no improvement in facial movement.

Examination

Static photography was used to assess and record the range of movement of his face in the following postures:

• At rest

• Small smile, lips together

• Large smile, lips apart

• Lip pucker

• Eye closure

• Eyebrow raise

• Open mouth wide

• Raise top lip/snarl

The Sunnybrook Facial Grading System was used to provide an objective measurement of the range of movement of the left side of his face, comparing it to the unaffected right side and expressed as a percentage. This scoring system not only measures range of movement, it also deducts marks for any signs of sykinesis, such as asymmetry at rest and aberrant linking of movements. Therefore it is a much more sensitive measure for patients who demonstrate significant synkinesis than the House Brackman scale which is widely used in British hospitals.

At his first attendance, JRK scored as follows:

Voluntary movement score 56%

Resting symmetry score -13%

Synkinesis score -14%

Complete score: 29%

Soft Tissue Assessment demonstrated shortening of the myofascia around the following muscles on the left side:

• Depressor Anguli Oris

• Depressor Labii Inferiors

• Risorius

• Zygomaticus major and minor

• Orbicularis Oculi

• Lower portion of Orbicularis Oris

Surface Electromyography (sEMG) was also used to evaluate the degree of nerve activity at each of the 4 main branches in the face, and proved a very useful part of treatment when employed for Biofeedback techniques.

Function of the Face

Patient JRK complained of problems with severe cramping in his right cheek on attempting to do large movements of his mouth. This restricted his facial movement when eating, yawning and laughing. He also experienced tension in his left cheek, and reported fatigue in this area on talking for prolonged periods.

Treatment

Treatment was given for a period of one year, during which the patient attended on 6 occasions at 2 monthly intervals, and it included the following treatment modalities:

1. Trophic Electrical Stimulation

2. sEMG Biofeedback

3. Myofascial Release Techniques

4. Home Stretches

5. Home Exercises

Results of Treatment

Static photography demonstrated improvement in facial symmetry in all 8 postures. Scoring with the Sunnybrook Facial Grading System improved by 25%, with the break-down as follows:

Voluntary movement score 68%

Resting symmetry score -8%

Synkinesis score -6%

Complete score: 54%

Function of the Face had improved significantly, with much reduction in the tension in the left cheek, and the problem of cramping on large movements resolved completely. Stamina on talking was improved, so the patient found that fatigue was no longer a problem.

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