Facial Aging, Wrinkles (rhytides)
Author(s): Tom Shokri, MD (Penn State Hershey Medical Center): Jessyka G Lighthall, MD (Penn State Hershey Medical Center)
The seventh cranial nerve (also known as the Facial Nerve) primarily serves a motor function (some fibers control a sensory component in the external auditory canal, salivation, or taste along the anterior tongue). Injury to the nerve, anywhere along its distribution from the facial nerve nucleus within the brainstem to its final innervation of the muscles of facial expression, may cause weakness or complete paralysis of the face.
Facial paralysis can result in one side of the face being partially or completely paralyzed.
This may cause: eyebrow sagging, drooping of the eye, and corner of the mouth, incomplete closure of the eye, nasal obstruction, epiphora (overflow of tears in the eye), or minor changes to hearing.
What to Expect at Your Otolaryngologist Office Visit:
Initially, your evaluation will begin with a review of your medical history. Be prepared to answer questions regarding your current and prior medical conditions. Your current medications will be reviewed as well as any surgical procedures you’ve had performed in the past. Tell your provider if you are allergic to any medications.
To best determine your treatment options, the physician will then perform a physical exam. The provider may also take photographs for your medical record. It is important to have a frank discussion regarding your expectations during your initial visit. Explain your main concerns and your goals with respect to your appearance. The risks, benefits, and realistic goals will be discussed.
If specific risk factors for a particular etiology are identified during your examination, then laboratory testing as well as imaging will be directed toward supporting or excluding a particular cause. Your doctor will order blood work to rule out any underlying infectious cause for your facial paralysis (Lyme disease, Herpes Zoster, etc.) or autoimmune condition. A CT scan with contrast of the face/neck and temporal bone or an MRI with contrast may be ordered to visualize possible sites of injury along the course of the facial nerve. Additionally, if a stroke or neural injury is suspected imaging may be recommended to rule this out.
For patients with complete facial paralysis, a electrophysiological test will likely be ordered 3-5 days following injury. Electroneuronography (ENoG) involves placement of electrodes that stimulate the facial nerve and measure muscle activity. If this test demonstrates greater than 90% degeneration, surgical decompression may be considered. This involves removal of the bony surroundings of the nerve. The need for surgery is addressed on case by case basis and is not recommended universally to all patients.
Steroids are effective in the treatment of facial nerve palsy. A steroid taper will be prescribed by your surgeon and should optimally be given within 72 hours of presentation of your symptoms. There is a moderate amount of evidence suggesting that adding antiviral medications to your steroid regimen may improve outcomes. This remains controversial although there are no significant adverse side effects to the medication. You will likely be referred to a Facial Nerve Center for reassessment of your facial paralysis and monitoring of your response to therapy. If you are unable to close your eye completely, lubricating eye drops and ointment will be recommended in addition to an eye moisture chamber which will allow for adequate moisturization of the globe and prevent injury to the cornea. If there is suspicion of injury to your eye, you may be referred to an ophthalmologist for further assessment. This is important in preventing irreversible blindness from corneal exposure and injury.
If it is suspected that your paralysis is due to Lyme Disease, you will be given an antibiotic, this may be in addition to steroid treatment. Your provider will reassess your response to therapy within several weeks. The late phase of treatment of facial paralysis is directed toward any residual facial movement deficits. Your surgeon will discuss any specific surgical interventions or long term therapies based on your symptoms. A number of medical and surgical options are available to treat patients who have long-term sequelae.