OVERVIEW
与病毒感染有关的面部肌肉无力或瘫痪
常表现为口角歪斜、眼睑闭合不全、鼓腮漏气
多与单纯疱疹病毒、带状疱疹病毒等病毒有关
药物治疗为主，可配合针灸、理疗
Definition
Viral facial paralysis is not a standardized name for the disease, but generally refers to damage to the facial nerve related to viral infection that causes facial nerve dysfunction, also known as idiopathic facial nerve palsy, facial neuritis, or Bell’s palsy, and is the most common form of peripheral facial paralysis.
Peripheral facial paralysis refers to damage to the facial nerve at or below the nucleus of the facial nerve. The facial nerve has the function of innervating the motor activity of the facial muscles, controlling the secretion of the lacrimal and salivary glands, and transmitting the sense of taste in the anterior 2/3 of the tongue as well as the sensation of the external auditory canal and auricle [1-2].
After lesions of the facial nerve occur, patients may present with crooked corners of the mouth, incomplete eyelid closure on one side, and leakage of wind in speech.
Pathogenesis
There is no authoritative data on the incidence of viral facial paralysis in China.
It can occur in people of any age, most often seen in 20-40 years old, more men than women, pregnant women have a higher incidence than ordinary women, with unilateral onset [3-4].
Etiology
Causes
The etiology of this disease is not clear, and is currently thought to be related to herpes simplex virus, herpes zoster virus and other neurophilic viral infections. It often develops after exposure to cold or upper respiratory tract infection [3-4].
Predisposing factors
Cold and cool wind irritation, recent upper respiratory tract infections, etc., can trigger the disease.
Predisposing factors
The disease is common in the following groups of people:
Diabetics, especially those with poor glycemic control.
Pregnant women, especially in late pregnancy.
Immunocompromised people, including those after organ transplantation and long-term use of immunosuppressants.
Pathogenesis
The facial nerve travels through a bony canal called the facial nerve canal, which is located in the skull near the ear.
Normally, the facial nerve is only 25% to 50% of the diameter of the canal, and the canal is very spacious.
Viral infections can lead to an autoimmune response and trophoblastic vasospasm in the facial nerve, causing facial nerve edema.
At this point, the facial nerve tract becomes crowded, and the edematous facial nerve is further compressed, resulting in neuronal dystrophy, demyelinating changes, and consequent dysfunction.
Symptoms
Viral facial paralysis starts rapidly, and symptoms can reach their most severe level in a few hours to a few days.
Many people show symptoms such as waking up with one side of the mouth crooked, leakage of air when speaking, and leakage of water when brushing teeth.
Main manifestations
The main manifestation is paralysis of one side of the facial muscles, and in rare cases, it can be seen bilaterally [5-6].
Frontal: forehead lines (headlines) become shallow.
Eyes: the eyes cannot be closed or are incompletely closed. When the eyes are closed, the eyeballs turn outward and upward, exposing the white sclera, the whites of the eyes, known as Bell’s sign.
Mouth: The corners of the mouth are crooked, speech leaks, drooling, and food residue is always left between the teeth and cheeks when eating.
Inability to successfully complete movements such as frowning, closing the eyes, whistling, etc., and in severe cases, the affected side of the face completely lose expression.
In severe cases, there is a complete loss of facial expression. In a few cases, there may be discomfort in the mouth, lips and cheeks.
Rare symptoms
The following symptoms may occur separately or together, and those that occur together are called Hunt’s syndrome.
Loss of taste in the front 2/3 of the tongue on the affected side.
Great discomfort with sounds of normal or even slight volume (auditory hypersensitivity).
Decreased sensation behind the ear, in the auricle, and in the external auditory canal.
Tiny herpes in the external auditory canal and tympanic membrane.
Consultation
Department of Medicine
Neurology
If you have symptoms such as crooked corners of the mouth, leaky speech, leaky brushing, inability to close your eyes, loss of facial expression, drooling, etc., it is recommended that you visit the Department of Neurology in a timely manner.
Other Departments
Patients may also visit the Department of Rehabilitation and the Department of Traditional Chinese Medicine for rehabilitation physiotherapy, acupuncture and other treatments.
Preparation
Consultation: Registration, Preparation of Information, Frequently Asked Questions
Tips for medical treatment
Try to record the symptoms, time of onset, duration, etc., so as to give the doctor more reference.
Keep your face clean and do not wear makeup.
Preparation Checklist
症状清单
Pay particular attention to the time of onset of symptoms, special manifestations, etc.
Are there any symptoms such as crooked corners of the mouth, leaky speech, leaky brushing, inability to close the eyes, loss of facial expression, drooling, etc.?
How long have these symptoms been occurring, how quickly did they develop, and have they ever gotten better?
Have you had wind, cold or flu before?
Has eating, drinking, or speaking been affected?
How is your hearing? Is there any tinnitus?
病史清单
Have you ever had wind, cold or flu before?
Do you have diabetes and how is your blood sugar control?
Have you had an organ transplant or taken immunosuppressants for a long time?
Are you pregnant?
What diseases have you had in the past?
检查清单
Test results in the last six months, which can be brought to the doctor’s office
Imaging tests: cranial CT, cranial magnetic resonance imaging.
Other tests: facial nerve electrogram, facial muscle electromyography.
用药清单
Medication in the last 3 months, if available, bring along the box or package for medical consultation
Glucocorticosteroids: dexamethasone, prednisone (prednisone), hydrocortisone.
Antivirals: acyclovir, vasiclovir, etc.
Neurotrophic drugs: vitamin B1, vitamin B12, methylcobalamin, etc.
Diagnosis
Diagnosis is based on
Medical history
The patient may have a history of colds and facial colds.
She may have diabetes, be pregnant, have undergone organ transplantation, or be on immunosuppressive drugs for a long time.
Clinical manifestations
症状
Sudden onset of symptoms such as crooked corners of the mouth, leakage of speech, leakage of brushing teeth, difficulty in closing the eyes, loss of facial expression, and salivation.
查体
Doctors mainly conduct neurological specialty examination.
Whether the patient has facial muscle paralysis is determined by the completion of frowning, frowning, eye closing and cheek puffing movements.
The external ear canal and auricular area are examined for herpes.
Determine the condition of the limb muscles by the patient’s movements such as lifting the hands, sitting up, standing and walking.
Slide a cotton swab over the patient’s skin or gently prick the skin with a blunt needle, and assess whether facial and limb sensory deficits are present based on the patient’s feedback.
Laboratory Tests
实验室检查
Virologic tests are performed to help the doctor find the cause of the disease.
If the presence of herpes simplex or herpes zoster virus infection is suspected, viral DNA and other monitoring may be performed.
影像学检查
A cranial magnetic resonance imaging or CT scan is performed, mainly to identify the presence of intracranial tumors, cerebrovascular lesions, skull fractures, and other conditions that may lead to symptoms of facial paralysis, and to help determine the cause of facial paralysis.
Patients with viral facial paralysis show no intracranial lesions on this test
神经电生理检查
Neurophysiological examination is mainly used to assess the severity of facial nerve damage, which is helpful for the doctor to determine the possibility of full recovery of facial nerve function and the necessity of facial nerve decompression surgery.
It includes electroneurography (ENoG) and electromyography (EMG).
Usually used in patients with severe symptoms or poor recovery.
量表检查
The House-Brackmann scale is commonly used to categorize patients into six grades from mild to severe [7].
Grade Symptom Description Gross View Resting State Motion
Grade I Normal Facial muscle movement in all regions Normal Normal Normal
Grade Ⅰ
Normal
Facial muscle movement in all regions Normal
Normal
Normal
Grade II mildly abnormal mild facial muscle weakness, there may be very light joint band movement facial symmetry, normal muscle tone normal frown normal, a little force to close the eyes completely, the corners of the mouth mildly asymmetric
Grade II
Mild abnormalities
Mild facial muscle weakness, may have very mild associated band movements.
Facial symmetry, normal muscle tone
Normal frontal crease, complete eye closure with slight force, mild asymmetry of the corners of the mouth
Grade III moderate abnormality marked facial muscle weakness, but no facial deformity, may have joint band movement, facial myoclonus or facial muscle spasm facial symmetry, muscle tone normal frontal fold is weakened, complete eye closure after exertion, the corners of the mouth are mildly asymmetric with maximum force
Grade III
Moderate abnormality
Obvious facial muscle weakness, but no facial deformation, may be associated with band movement, facial myoclonus or facial muscle spasm
Facial symmetry, normal muscle tone
Decreased frontal crease, complete eye closure after exertion, mild asymmetry of the corners of the mouth after maximal force.
Grade IV Moderate to severe abnormally pronounced facial muscle weakness and/or facial deformity with facial symmetry, normal muscle tone, inability to wrinkle the forehead, incomplete eye closure, and asymmetry of the corners of the mouth after maximal force.
Grade IV
Moderately severe abnormality
Significant facial muscle weakness and/or facial deformity.
Facial symmetry, normal muscle tone
Inability to wrinkle forehead, incomplete eye closure, asymmetry of the corners of the mouth with maximal force
Grade V severe abnormality with only barely perceptible facial movements facial asymmetry, inability to wrinkle forehead, incomplete eye closure, slight movement of the corners of the mouth
Grade V
Severe abnormalities
Almost imperceptible facial movements only
Facial asymmetry
Inability to wrinkle forehead, incomplete eye closure, slight movement of mouth corners
Grade VI complete paralysis, no movement complete paralysis, no movement complete paralysis, no movement complete paralysis, no movement
Grade VI
Complete paralysis, no movement
Complete paralysis, no movement
Complete paralysis, no movement
Complete paralysis, no movement
Differential Diagnosis
A variety of disorders can cause facial paralysis and require differentiation between causes of peripheral nerve facial paralysis and peripheral versus central facial paralysis [7-9].
DiseaseGuillain-Barré syndromeLyme diseaseOtitis mediaStroke
Etiology autoimmune reaction Lyme disease spirochete infection bacterial or viral pathogens cerebral ischemia, cerebral hemorrhage
Etiology
Autoimmune response
Lyme disease spirochete infection
Bacterial or viral pathogen
Cerebral ischemia, cerebral hemorrhage
Differentials Bilateral onset is more common with a history of tick bites, rash or arthralgia, and travel to Lyme endemic areas with gradual onset of ear pain, fever, and hearing loss, often with limb weakness, limb sensory deficits, and changes in speech and awareness
Points of differentiation
Bilateral onset is more common
History of tick bites, rash or joint pain, travel to Lyme disease endemic areas
Gradual onset of earache, fever, hearing loss
Most of the limbs are not involved, often with limb weakness, limb sensory deficits, and changes in speech and consciousness.
Treatment
Aim of treatment: to promote the local inflammation and edema to subside as soon as possible, to promote the recovery of nerve function, and to prevent sequelae.
Treatment principle: drug treatment is the mainstay, can be combined with acupuncture, rehabilitation therapy.
Drug treatment
Acute stage
Within 1~2 weeks of the onset of the disease can be regarded as the acute stage, mainly to control tissue edema, improve local blood circulation and reduce nerve damage.
Glucocorticoid: Dexamethasone, prednisone, hydrocortisone, etc. can be used. Care should be taken not to use them for a long time to avoid adverse reactions such as abnormal blood sugar and gastrointestinal discomfort.
Antiviral drugs: mainly acyclovir, often used in combination with glucocorticoids. Headache, nausea and vomiting, skin rash and other adverse reactions should be noted.
Neurotrophic drugs: in order to promote the repair of nerve myelin, often use vitamin B1, vitamin B12, methylcobalamin and other drugs.
Eye medication: To reduce or avoid corneal dryness and damage, artificial tear drops, erythromycin eye ointment and other medications can be used, usually more often at bedtime.
Recovery period
Within 6 months of the onset of the disease is the recovery period, the purpose of the treatment is to restore the nerve conduction function as soon as possible and strengthen the muscle contraction.
In addition to the use of neurotrophic drugs, niacin and diprazole can be used to improve local blood supply and relieve symptoms.
If the facial nerve function still cannot be restored in 3 months, it belongs to the sequela period, and surgical treatment can be attempted.
Rehabilitation Treatment
Physical factor therapy
Acute stage: infrared ray and ultra-short wave treatment can effectively improve blood circulation around the nerve.
Recovery stage: Electric stimulation can effectively promote the recovery of facial nerve function.
Rehabilitation training
Rehabilitation training helps to restore facial symmetry and voluntary control of facial muscles.
Facial muscle massage: use the root of the palm to press and knead from the corner of the mouth of the affected side upward in a spiral pattern for 5-10 minutes each time, 2-3 times a day, the force should be soft and moderate.
Facial movement training: including practicing eating, drinking, raising eyebrows, blinking, smiling, pouting, showing teeth, puffing out cheeks and other movements, 2 to 3 times a day, 10 to 20 times for each movement.
参考文献
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