Facial Pain and/or weakness (Causes of Facial Pain (Sinus: sinusitis,…
Facial Pain and/or weakness
Causes of Facial Pain
sinusitis, trauma, carcinoma
URTI, nasal injury and foreign bodies, Nasopharyngeal carcinoma (common in Chinese populations
otitis media, otitis externa
HZV, Post-herpetic neuralgia, Trigeminal neuralgia
temporomandibular dysfunction and cellulitis
Mumps, Parotitis, Tumour
Cluster, migraine, Temporal arteritis
Causes of Facial Weakness
Idiopathic (Bell's palsy):
Pregnancy - 3x more common or in DM
(eg, brainstem stroke).
Local for dental treatment or linezolid
Herpesvirus (type 1).
Herpes zoster (Ramsay Hunt syndrome)
Fractures of the skull base.
Haematoma after acupuncture.
Mononeuropathy - eg, due to diabetes mellitus, sarcoidosis or amyloidosis.
Posterior fossa tumours, primary and secondary.
Parotid gland tumours.
Hypertension in pregnancy and eclampsia.
Melkersson-Rosenthal syndrome (recurrent facial palsy, chronic facial oedema of the face and lips, and hypertrophy/fissuring of the tongue)
Sjögren's syndrome and rheumatoid arthritis
Lyme disease (more likely if bilateral when responsible for 36% of cases).
Otitis media or cholesteatoma.
Intracranial tumours, primary and secondary
History - Facial Pain
Establish if unilateral or bilateral and whether it relates to a nerve distribution.
occurs in dental conditions, trigeminal neuralgia, salivary gland conditions. Pain may be
either bilateral or unilateral
in sinus infection, temporomandibular disorders, headaches and giant cell arteritis.
Pain in the region of the ear may be referred from the skin, teeth, tonsils, pharynx, larynx or neck.
Tenderness over the maxilla may be due to sinusitis, dental abscess or carcinoma.
Establish whether it is continuous or episodic and the severity and nature of the pain.
intermittent sharp, severe pain in the distribution of the divisions of the trigeminal nerve.
Infections of teeth, mastoid and ear:
often dull, aching quality.
Precipitated by food or chewing:
dental abscess, salivary gland disorder, temporomandibular joint disorder or jaw claudication due to temporal arteritis.
can be precipitated by various factors, including eating, talking and touching or washing the face. Even the slightest touch of the skin can cause intense pain.
Obstruction of the lacrimal duct by nasopharyngeal carcinoma may cause watering of the eyes.
Otorrhoea and/or hearing loss suggest an ear or mastoid cause.
Nasal obstruction and rhinorrhoea may be due to maxillary sinusitis or carcinoma of the maxillary antrum. Carcinoma of the maxillary antrum may also present with unilateral epistaxis.
Proximal muscle weakness and pain may be due to polymyalgia rheumatica, associated with temporal arteritis.
Intermittent presence of a lump around the jaw may suggest salivary duct obstruction
Paraesthesia in the trigeminal n area tends to precede the unilateral rash of Herpes Zoster
Investigations - Facial Pain
raised white cell count in infection or malignancy.
increase in infection, malignancy, temporal arteritis.
Dental x-rays can be carried out by community dentists where there is suspected dental pathology.
Opacification of the sinus and destruction of bone with carcinoma of sinuses.
Opacification may also occur in sinusitis.
Mastoid films may show opacification in cases of mastoiditis.
Ultrasound scans are useful as first-line investigation for suspected salivary gland pathology.
MRI or CT scans
may be necessary for some conditions e.g. tumours (extent and invasion); CT is good for sinus tumours, nasopharyngeal tumours
parotid conditions - e.g. duct stones, sialectasis.
Temporal Artery Biopsy:
Unilateral erythema and vesicles in the distribution of the trigeminal nerve: herpes zoster infection (may not be present in the early stages of the disease).
Localised erythema or swelling: localised infection or carcinoma.
Inspection of the nose and throat may demonstrate a nasopharyngeal tumour.
Examine the cranial nerves.
may be due to a tumour of the parotid gland.
Tenderness of the superficial temporal artery associated with temporal arteritis.
Tenderness over one or more sinuses may indicate sinus infection.
Cervical lymphadenopathy: infection or carcinoma.
Lumps over the parotid area may indicate salivary gland tumours or blockage of the gland (whether the lump is intermittently present or continuously so is helpful).
Pain or crepitus on movement of the jaw may indicate temporomandibular joint dysfunction.
Acute LMN palsy
Acute LMN palsy can present at any age but is most frequently seen at age 15-60 years, affecting both sexes equally. There is a rapid onset of unilateral facial paralysis:
Ask the patient to give a big grin showing their teeth.
Ask them to blow out their cheeks.
Ask them to screw up their eyes.
Ask them to raise their eyebrows (preserved in UMN lesion).
Aching pain below the ear or in the mastoid area is also common and may suggest middle ear or herpetic cause.
There may be hyperacusis.
Patients with lesions proximal to the geniculate ganglion may be unable to produce tears and have loss of taste.
Probably caused by ischaemic compression of the facial nerve within the facial canal, as a result of inflammation, most likely due to a viral infection.
In the past no cause was found in the majority of cases of LMN facial nerve palsy and these were labelled as idiopathic (ie Bell's palsy). Increasingly, various viral causes are being identified, particularly herpes simplex type 1 or varicella (herpes) zoster.
Approximately 7% of patients have a recurrence.
The incidence is higher in people with diabetes than in those without diabetes.
Usually unilateral paralysis of the face but can be bilateral
You may not be able to close an eye. This may cause a watery or dry eye.
You may not be able to wrinkle your forehead, whistle or blow out your cheek.
Face may droop to one side. When you smile, only half of face may move.
Ramsay Hunt Syndrome
LMN facial nerve palsy due specifically to varicella (herpes) zoster is Ramsay Hunt syndrome.
Pain is often a prominent feature and vesicles are seen in the ipsilateral ear, on the hard palate and/or on the anterior two thirds of the tongue.
It can include deafness and vertigo and other cranial nerves can be affected.
It should be suspected when pain is significant, especially in those aged over 60. Immunodeficiency - for example, HIV - is a risk factor.
History - Facial Weakness
Weakness of the muscles of facial expression and eye closure. The face sags and is drawn across to the opposite side on smiling. Voluntary eye closure may not be possible and can produce damage to the conjunctiva and cornea.
In partial paralysis, the lower face is generally more affected.
In severe cases, there is often demonstrable loss of taste over the anterior two thirds of the tongue and intolerance to high-pitched or loud noises. It may cause mild dysarthria and difficulty with eating.
(most common system used for describing the degree of paralysis) where 1 is normal power and 6 is total paralysis.
Is it an UMN or LMN lesion?
In an LMN lesion, the patient can't wrinkle their forehead - the final common pathway to the muscles is destroyed. The lesion must be either in the pons, or outside the brainstem (posterior fossa, bony canal, middle ear or outside skull).
In a UMN lesion, the upper facial muscles are partially spared because of alternative pathways in the brainstem, ie the patient can wrinkle their forehead (unless there is bilateral lesion) and the sagging of the face seen with LMN palsies is not as prominent. There appear to be different pathways for voluntary and emotional movement.
Cerebrovascular accidents usually weaken voluntary movement, often sparing involuntary movements (eg, spontaneous smiling). The much rarer selective loss of emotional movement is called mimic paralysis and is usually due to a frontal or thalamic lesion.
Investigations - Facial Weakness
Check blood pressure in children with Bell's palsy (two case reports of aortic coarctation presenting with facial nerve palsy and hypertension).
- Lyme, herpes and zoster (paired samples 4-6 weeks apart). It may not influence management but may reveal aetiology.