11 - Eyelid and Facial Abnormalities

Question 1

Cranial Nerve 7 Disorders

Answer 1

Question 2

Cranial Nerve 7 Disorders - Supranuclear Lesions

Answer 2

1. Involves Lower face paralysis > Upper face paralysis of contralateral face
2. Emotional and reflex movements such as smiling and spontaneous blinking preserved

Question 3

Cranial Nerve 7 Disorders - Brainstem Lesion

Answer 3

1. Usually from Vascular lesions or Intraparenchymal tumors

Question 4

Cranial Nerve 7 Disorders - Brainstem Lesion

Answer 4

Question 5

Bell’s Palsy

Answer 5

1. Peripheral CN7 lesion
2. Ipsilateral facial weakness; may also see decreased tearing, diminished taste, dysacusis
3. 2/2 Autoimmune, viral-induced, ischemic injury with swelling of peripheral nerve
4. Higher incidence in pregnant women, DM2, family hx
5. If progresses for more than 3 weeks consider neoplastic process, inflammatory (sarcoidosis), infection
6. 85% patients recover within 3 weeks of onset and complete by 2-3 months (subtle signs of aberrant generation may be seen). In remaining patients recovery incomplete and significant synkinesis common.
7. Tx — 7-10 days of corticosteroids +/- anti-virals

Question 6

Cranial Nerve 7 Disorders - Peripheral Lesions

Answer 6

1. Neoplasm may involve CNVII in cerebellopontine angle (acoustic neuroma, meningioma), within fallopian canal or parotid gland
   
   1. MRI needed
2. Lyme disease — Unilateral or Bilateral facial palsy with arthritis, rash, meningopolyneuritis
3. Herpes Zoster — Ramsay Hunt when involves CN7

Question 7

CN7 palsy underactivity treatment

Answer 7

1. Lubricants + ATs + taping eyelid shut with lubricating ointment at night
2. Breakdown of K epithelium — punctal plugs, tarsorrhaphy + botulinum to induce ptosis
3. Patients with CN 7 palsy important to determine CN5 status — loss of K sensation (neurotrophic keratitis) + CN7 palsy (neuroparalytic keratitis) warrants aggressive approach possibly with early tarsorrhaphy or eyelid weight implant
4. Simplest and most successful — eyelid weights + LTS. Heaviest weight thta can be lifted clear of visual axis should be chosen. If nerve function returns then weight can be removed

Question 8

Benign Essential Blepharospasm

Answer 8

1. Due to overactivity 2/2 disorders of CN7, CN7 nucleus, pyramidal/extrapyramidal pathways
2. Bilateral episodic contraction of orbicularis muscle
3. Facial grimacing + blepharospasm = Meige syndrome
4. Extrapyramidal disorders — parkinsonism, Huntington disease, basal ganglia infarction may be associated with blepharospasm
5. 2/2 Basal Ganglia dysfunction
6. Should exclude secondary causes of BEB including severe dry eye, intraocular inflammation, meningeal irritation.
7. Stress may exacerbate condition
8. Botulimum toxin injection may be used — may cause ptosis, ecchymosis, ectropion, diplopia, lagophthalmos, exposure keratopathy
9. Surgical myectomy for refractory botulinum injections

Question 9

Hemifacial Spasm

Answer 9

1. Unilateral episodic spasms involving facial musculature lasting seconds to minutes
2. Can occur in sleep
3. Most commonly from compression of CN7 root exit zone by dolichoectatic vessel
4. May be due to Bell palsy, demyelination
5. MRI and MRA performed to exclude compressive lesion
6. Botulimun injection treatment of choice
7. Carbamazepine, baclofen, clonazepam may provide improvement

Question 10

Spastic Paretic Facial Contracture

Answer 10

1. Unilateral facial contracture with associated facial weakness

Question 11

Facial Myokymia

Answer 11

1. Continuous unilateral fibrillary or undulating contraction of facial muscle bundles
2. Typically signifies intramedullary disease of pons involving CN7 nucleus or fascicle
3. Pontine glioma in children and multiple sclerosis in adults
4. Slowly progressive facial myokymia suggests brainstem mass
5. May be relieved with carbamezapine, botulin injection, phenytoin

Question 12

Eyelid Myokymia

Answer 12

1. Intermittent fluttering of orbicularis oculi
2. 2/2 caffeine, stress, sleep deprivation

Question 13

Habit Spasm

Answer 13

1. Facial or nervous tic
2. Reassurance