Twitching, weakness, or paralysis of the face are symptoms of a disorder involving the facial nerve, not a disease in itself. Abnormal movement or paralysis of the face can result from infection, injury, or tumors, and an evaluation by your physician is needed to determine the cause. An otolaryngologist– head and neck surgeon has special training and experience in managing facial nerve disorders.
The facial nerve resembles a telephone cable and contains 7,000 individual nerve fibers. Each fiber carries electrical impulses to a specific facial muscle. Information passing along the fibers of this nerve allows us to laugh, cry, smile, or frown, hence the name, “the nerve of facial expression.”
When half or more of these individual nerve fibers are interrupted, facial weakness occurs. If these nerve fibers are irritated, then movements of the facial muscles appear as spasms or twitching. The facial nerve not only carries nerve impulses to the muscles of the face, but also to the tear glands, to the saliva glands, and to the muscle of the stirrup bone in the middle ear (the stapes). It also transmits taste from the front of the tongue. Since the function of the facial nerve is so complex, many symptoms may occur when the fibers of the facial nerve are disrupted. A disorder of the facial nerve may result in twitching, weakness, or paralysis of the face, in dryness of the eye or the mouth, or in disturbance of taste.
The anatomy of the facial nerve is very complex. The facial nerve passes through the base of the skull in transit from the brain to the muscles of facial expression. After leaving the brain, the facial nerve enters the bone of the ear (temporal bone) through a small bony tube (the internal auditory canal) in very close association with the hearing and balance nerves. Along its inch-and-a-half course through a small canal within the temporal bone, the facial nerve winds around the three middle ear bones, in back of the eardrum, and then through the mastoid (the bony area behind the part of the ear that is visible). After the facial nerve leaves the mastoid, it passes through the salivary gland in the face (parotid gland) and divides into many branches, which supply the various facial muscles. The facial nerve gives off many branches as it courses through the temporal bone: to the tear gland, to the stapes muscle, to the tongue (for taste sensation), and to the saliva glands.
The most common cause of facial weakness which comes on suddenly is referred to as “Bell’s palsy.” This disorder is probably due to the body’s response to a virus: in reaction to the virus the facial nerve within the ear (temporal) bone swells, and this pressure on the nerve in the bony canal damages it.
In order to be sure that this is the cause of the facial weakness, and not something else, a special set of questions will be asked. After an examination of the head, neck, and ears, a series of tests may be performed. The most common tests are:
The three questions most often asked by the patient are:
In order to answer these questions, your doctor must perform an extensive evaluation to determine the cause and which area of the facial nerve is involved, so that the best treatment can be prescribed.
The results of diagnostic testing will determine treatment.
When the facial nerve is paralyzed, considerable attention must be given to maintaining a healthy eye, which requires a constant flow of tears. These tears are spread out over the eye by blinking, but blinking is diminished or eliminated in facial nerve paralysis. Diminished blinking and the absence of tearing together can reduce or eliminate the flow of tears across the eyeball, resulting in drying, erosion, and ulcer formation on the cornea and possible loss of the eye.
Closing the eye with a finger is an effective way of keeping the eye moist. Use the back of the finger to ensure that the eye is not injured with the finger tip. Protective glasses or clear eye patches are often used to keep the eye moist, and to keep foreign materials from entering the eye.
If the eye is dry, you may be advised to use artificial tears to keep it moist. The drops should be used as directed by your doctor. You may have to put one or two drops in the affected eye every hour while you are awake, and place ointment in your eye at bedtime.
Patients with permanent facial paralysis may be rehabilitated through a variety of surgical procedures including eyelid weights or springs, muscle transfers and nerve substitutions. Some patients may benefit from a special form of physical therapy called facial retraining. Other medical treatments for complications of facial paralysis including excessive motion of the face or muscle spasm may involve surgical division of over-active muscles or weakening them by chemical injection. If these procedures are needed, your physician will discuss them with you.
Disorders of the facial nerve, including paralysis, are not rare and have a variety of causes. The appropriate diagnosis and treatment are very important to achieving the best possible recovery of facial nerve function. Even patients with permanent facial nerve injury can be helped by surgical procedures designed to improve facial function.
Playing catch, shooting hoops, bicycling on a scenic path or just kicking around a soccer ball have more in common than you may think. On the up side, these activities are good exercise and are enjoyed by thousands of Americans. On the down side, they can result in a variety of injuries to the face.
Many injuries are preventable by wearing the proper protective gear, and your attitude toward safety can make a big difference. However, even the most careful person can get hurt. When an accident happens, it's your response that can make the difference between a temporary inconvenience and permanent injury.
When someone gets hurt:
Sports injuries can cause potentially serious broken bones or fractures of the face. Common symptoms of facial fractures include:
It is important to pay attention to swelling because it may be masking a more serious injury. Applying ice packs and keeping the head elevated may reduce early swelling. If any of these symptoms occur, be sure to visit the emergency room or the office of a facial plastic surgeon. (such as an otolaryngologist-head and neck surgeon) where x-rays may be taken to determine if there is a fracture.
When you are hit in the upper face (by a ball for example) it can fracture the delicate bones around the sinuses, eye sockets, bridge of the nose or cheek bones. A direct blow to the eye may cause a fracture, as well as blurred or double vision. All eye injuries should be examined by an eye specialist (ophthalmologist).
When your jaw or lower face is injured, it may change the way your teeth fit together. To restore a normal bite, surgeries often can be performed from inside the mouth to prevent visible scarring of the face; and broken jaws often can be repaired without being wired shut for long periods. Your doctor will explain your treatment options and the latest treatment techniques.
Bruises cuts and scrapes often result from high speed or contact sports, such as boxing, football, soccer, ice hockey, bicycling skiing, and snowmobiling. Most can be treated at home, but some require medical attention. You should get immediate medical care when you have:
Also called contusions, bruises result from bleeding underneath the skin. Applying pressure, elevating the bruised area above the heart and using an ice pack for the first 24 to 48 hours minimizes discoloration and swelling. After two days, a heat pack or hot water bottle may help more. Most of the swelling and bruising should disappear in one to two weeks.
The external bleeding that results from cuts and scrapes can be stopped by immediately applying pressure with gauze or a clean cloth. When the bleeding is uncontrollable, you should go to the emergency room.
Scrapes should be washed with soap and water to remove any foreign material that could cause infection and discoloration of the skin. Scrapes or abrasions can be treated at home by cleaning with 3% hydrogen peroxide and covering with an antibiotic ointment or cream until the skin is healed. Cuts or lacerations, unless very small, should be examined by a physician. Stitches may be necessary, and deeper cuts may have serious effects. Following stitches, cuts should be kept clean and free of scabs with hydrogen peroxide and antibiotic ointment. Bandages may be needed to protect the area from pressure or irritation from clothes. You may experience numbness around the cut for several months. Healing will continue for 6 to 12 months. Scars that look too obvious after this time should be seen by a facial plastic surgeon.
Perhaps because it protrudes, the nose is one of the most injured areas on the face. Early treatment of a nose injury consists of applying a cold compress and keeping the head higher than the rest of the body. You should seek medical attention in the case of:
Nosebleeds are common and usually short-lived. Often they can be controlled by squeezing the nose with constant pressure for 5 to 10 minutes. If bleeding persists, seek medical attention. Bleeding also can occur underneath the surface of the nose. An otolaryngologist/facial plastic surgeon will examine the nose to determine if there is a clot or collection of blood beneath the mucus membrane of the septum (a septal hematoma) or any fracture. Hematomas should be drained so the pressure does not cause nose damage or infection.
Some otolaryngologist-head and neck specialists set fractured bones right away before swelling develops, while others prefer to wait until the swelling is gone. These fractures can be repaired under local or general anesthesia, even weeks later. Ultimately, treatment decisions will be made to restore proper function of the nasal air passages and normal appearance and structural support of the nose. Swelling and bruising of the nose will last for 10 days or more.
Whether seemingly minor or severe, all neck injuries should be thoroughly evaluated by an otolaryngologist. Injuries may involve specific structures within the neck, such as the larynx (voicebox), esophagus (food passage), or major blood vessels and nerves.
The larynx is a complex organ consisting of cartilage, nerves and muscles with a mucous membrane lining all encased in a protective tissue (cartilage) framework. The cartilages can be fractured or dislocated; either is serious because of the possibility of injuring the airway and obstructing breathing. Hoarseness or difficulty breathing after a blow to the neck are warning signs of a serious injury and the injured person should receive immediate medical attention.
The best way to treat facial sports injuries is to prevent them. To insure a safe athletic environment, the following guidelines are suggested:
Open your jaw all the way and shut it. This simple movement would not be possible without the Temporo-Mandibular Joint (TMJ). It connects the temporal bone (the bone that forms the side of the skull) and the mandible (the lower jaw). Even though it is only a small disc of cartilage, it separates the bones so that the mandible may slide easily whenever you talk, swallow, chew, kiss, etc. Therefore, damage to this complex, triangular structure in front of your ear, can cause considerable discomfort.
You can locate this joint by putting your finger on the triangular structure in front of your ear. Then move your finger just slightly forward and press firmly while you open your jaw all the way andclose it. You can also feel the joint motion in your ear canal.
When you bite down hard, you put force on the object between your teeth and on the Temporo-Mandibular Joint. In terms of physics, the jaw is the lever and the TMJ is the fulcrum. Actually, more force is applied (per square foot) to the joint surface than to whatever is between your teeth because the cartilage between the bones provides a smooth surface, over which the joint can freely slide with minimal friction.
Therefore, the forces of chewing can be distributed over a wider surface in the joint space and minimize the risk of injury. In addition, several muscles contribute to opening and closing the jaw and aid in the function of the TMJ.
In most patients, pain associated with the TMJ is a result of displacement of the cartilage disc that causes pressure and stretching of the associated sensory nerves. The popping or clicking occurs when the disk snaps into place when the jaw moves. In addition, the chewing muscles may spasm, not function efficiently, and cause pain and tenderness.
Damage to the TMJ is often caused by:
The pain may be sharp and searing, occurring each time you swallow, yawn, talk, or chew, or it may be dull and constant. It hurts over the joint, immediately in front of the ear, but pain can also radiate elsewhere. It often causes spasms in the adjacent muscles that are attached to the bones of the skull, face, and jaws. Then, pain can be felt at the side of the head (the temple), the cheek, the lower jaw, and the teeth.
A very common focus of pain is in the ear. Many patients come to the ear specialist quite convinced their pain is from an ear infection. When the earache is not associated with a hearing loss and the eardrum looks normal, the doctor will consider the possibility that the pain comes from a TMJ dysfunction.
There are a few other symptoms besides pain that TMJ dysfunction can cause. It can make popping, clicking, or grinding sounds when the jaws are opened widely. Or the jaw locks wide open (dislocated). At the other extreme, TMJ dysfunction can prevent the jaws from fully opening. Some people get ringing in their ears from TMJ trouble.
Because TMJ symptoms often develop in the head and neck, otolaryngologists are appropriately qualified to diagnose TMJ problems. Proper diagnosis of TMJ begins with a detailed history and physical, including careful assessment of the teeth occlusion and function of the jaw joints and muscles. An early diagnosis will likely respond to simple, self-remedies:
In cases of joint injury, apply ice packs soon after the injury to reduce swelling. Relaxation techniques and stress reduction, patient education, non-steroidal anti-inflammatory drugs, muscle relaxants or other medications may also offer relief.
Other treatments for advanced cases may include fabrication of an occlusal splint to prevent wear and tear on the joint, improving the alignment of the upper and lower teeth, and surgery. After diagnosis, your otolaryngologist may suggest further consultation with your dentist and oral surgeon to facilitate effective management of TMJ dysfunction.
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