Peripheral (Seventh) Nerve Palsy and Multiple Sclerosis: A Diagnostic Dilemma - A Case Report

Modified hypoglossal-facial nerve anastomosis for peripheral-type facial palsy caused by pontine infarction: A case report and literature review

Background

Peripheral-type facial palsy could be caused by a lesion in the tegmentum of the pons, such as infarction, with a rare occurrence. We herein described a case of unilateral peripheral-type facial palsy induced by dorsolateral pontine infarction and treated this patient using modified hypoglossal-facial nerve anastomosis.

Case presentation

A 60-year-old female presented with dizziness, hearing drop, diplopia, and peripheral-type facial palsy. Brain Magnetic Resonance Imaging showed a dorsolateral pontine infarction on the right side which exactly refers to the location of the ipsilateral facial nucleus or facial nerve fascicles at the pons. Subsequent electrophysiological examinations confirmed poor facial nerve function of this patient and modified hypoglossal-facial nerve anastomosis was then performed.

Conclusions

This case reminded medical practitioners not to ignore the possibility of involvement of a central cause in peripheral-type facial palsy patients. In addition, modified hypoglossal-facial nerve anastomosis served as a useful skill improvement that may help reduce hemiglossal dysfunction while restoring facial muscle function.

Episodic Facial Paresis-An Isolated Presenting Symptom of Multiple Sclerosis

This case report describes a case of a man in his 30s who presented with episodic right lower facial paresis for 10 days and was diagnosede with an episodic, transient pattern of unilateral facial palsy associated with relapsing remitting multiple sclerosis.

Bell felcinin viral patojenitesi ve tedavi olarak botulinum toksin tip A kullanımı

Bell'in felci, kraniyal sinir VII'nin iltihaplanmasının ortak adıdır. Kendine özgü genikulat ganglion iltihabı idiyopatiktir ve hemifasiyal felce neden olur. Bu felçten muzdarip olan hastaların semptomları 3 hafta ile 3 ay arasında kaybolabilir. Yüz felci devam eden bazı hastalar için botulinum toksin tip A etkili bir tedavi olabilir. Kas felcinin şiddetine göre botoksun yanı sıra ameliyat, steroid ve antiviral tedavi gibi farklı tedaviler sunulabilir. Bu derleme makalesinin amacı, viral patojenlerin fasiyal sinir iltihabının aktivasyonu ile olası ilişkisine ve Bell felçli hastaların tedavi olarak botoks tip-A'dan nasıl yararlanabileceğine dalmaktır.

Facial Palsy, Radiographic and Other Workup Negative: FROWN

Objectives

Slow-onset peripheral facial palsy is far less common than acute-onset peripheral facial palsy and necessitates diagnostic evaluation for benign or malignant tumors or other less common etiologies. In the rare scenario in which no clarifying etiology is discovered following long-term evaluation (no radiographic or hematologic abnormalities and an otherwise unremarkable evaluation), a diagnostic and management dilemma occurs. We present a series of patients with this possible new clinical entity: Facial palsy, Radiographic and Other Workup Negative (FROWN) and propose a management strategy for this diagnosis of exclusion.

Methods

A series of 3,849 patients presenting with facial palsy to a tertiary facial nerve center was retrospectively assessed to identify those with progressive loss of facial function over at least 1 month. Exclusion criteria were history, physical or hematologic findings indicative of known diseases associated with facial palsy, and radiographic studies demonstrating a benign or malignant tumor.

Results

Patients with slow-onset facial palsy constituted 5% (190 patients) of the cohort and were ultimately diagnosed with either a benign or malignant neoplasm or other facial nerve pathology. Fourteen patients with slow-onset facial palsy remained without a diagnosis following long-term evaluation and serial imaging. Eleven patients underwent dynamic facial reanimation surgery and facial nerve and muscle biopsy, with no clear histopathologic diagnosis.

Conclusion

Patients with slow-onset facial palsy with negative radiographic and medical evaluations over several years may be characterized as having FROWN, an idiopathic and as yet poorly understood condition, which appears to be amenable to facial reanimation but requires further investigation as to its pathophysiology.

Myasthenia Gravis Masquerading as an Idiopathic Unilateral Facial Paralysis (Bell's Palsy)-A Very Rare and Unique Clinical Find

Myasthenia gravis (MG) is an uncommon autoimmune neuromuscular junction disorder manifesting as fluctuating weakness of skeletal muscles. To add to its repertoire of mimicking a wide range of neurological disorders, the present case report is, to the best of our knowledge, the very first to describe MG masquerading as an idiopathic unilateral facial paralysis (Bell's palsy, BP). Our case report is distinct, highlights a novel clinical occurrence, offers new insights of how different neurological disorders may overlap with each other, and reminds neurologists to have a very broad and thorough comprehension for effective diagnoses and treatment plans. Several other conditions that produce facial nerve palsy identical to BP have also been discussed.

Clinical and radiological findings of facial paralysis in multiple sclerosis

BACKGROUND

Diagnosis of central or peripheral facial palsy (FP) is traditionally based on clinical evaluation. This study aims at investigating the relationship between clinical evaluation of FP and lesion location as visible on Magnetic Resonance Imaging (MRI) in patients with Multiple Sclerosis (MS) for the purpose of adding supporting evidence to the diagnosis of central or peripheral FP in these patients.

METHODS

A retrospective study was conducted on data from patients who underwent MS treatment between January 2016 and January 2019 at the MS Center of Wayne State University, MI, USA, and presented with at least one episode of FP during the observational period. The following data was collected from each patient: demographics, time from MS onset, side of FP, FP type (central or peripheral, as clinically evaluated), FP onset, FP treatment, amount of recovery of normal facial movements, time elapsed from beginning of FP treatment, number of FP recurrences, lesions presence/absence and location as visible on MRI. Correlation analysis was performed to assess to which extent clinical evaluation of FP correlated with presence of MRI lesions in different locations.

RESULTS

Eighteen patients were included in this study. In thirteen patients (72.2%) FP was classified as peripheral. Among them only five (38.4%) displayed one or more lesions in the pons. Correlation between presence of lesions in the pons and presence of peripheral FP was statistically significant (p = 0.02). Correlation between presence of lesions in the cortex (observed in 61.5% of patients with FP clinically evaluated as peripheral) and presence of FP clinically evaluated as peripheral was also statistically significant (p = 0.01). Finally, presence of lesions in the cortex was significantly correlated with presence of FP clinically evaluated as central (p = 0.02).

CONCLUSIONS

FP clinically classified as peripheral may be caused by central lesions in the cortex or pons and not only by peripheral facial nerve damage. In MS patients, FP may appear at the onset of the disease and be misdiagnosed as Bell 's palsy. Clinicians should carefully approach FP diagnosis and perform a brain as well as temporal bone MRI before pursuing pharmacological treatment.

Pattern Recognition of the Multiple Sclerosis Syndrome

During recent decades, the autoimmune disease neuromyelitis optica spectrum disorder (NMOSD), once broadly classified under the umbrella of multiple sclerosis (MS), has been extended to include autoimmune inflammatory conditions of the central nervous system (CNS), which are now diagnosable with serum serological tests. These antibody-mediated inflammatory diseases of the CNS share a clinical presentation to MS. A number of practical learning points emerge in this review, which is geared toward the pattern recognition of optic neuritis, transverse myelitis, brainstem/cerebellar and hemispheric tumefactive demyelinating lesion (TDL)-associated MS, aquaporin-4-antibody and myelin oligodendrocyte glycoprotein (MOG)-antibody NMOSD, overlap syndrome, and some yet-to-be-defined/classified demyelinating disease, all unspecifically labeled under MS syndrome. The goal of this review is to increase clinicians’ awareness of the clinical nuances of the autoimmune conditions for MS and NMSOD, and to highlight highly suggestive patterns of clinical, paraclinical or imaging presentations in order to improve differentiation. With overlay in clinical manifestations between MS and NMOSD, magnetic resonance imaging (MRI) of the brain, orbits and spinal cord, serology, and most importantly, high index of suspicion based on pattern recognition, will help lead to the final diagnosis.