No facial movement bilaterally post CVA
Quick clinical consult Hi Dr Mason I have a quick clinical consult for you- this is not my patient so I don’t have all the details, I was just hoping I could pick your brain to see if anything popped out for you. Mid 30s male suffered a small right occipital lobe CVA. Found face down on the floor after undetermined amount of time with contusions on forehead/chin. Brought to hospital- SLP consult 2 days later due to ‘no facial movement bilaterally’. Upon screening the SLP said client has no cognitive language deficits, normal range of motion and strength of lips and jaw but NO lip or facial movement (ie., can’t raise his eye brows). Sensation appears to be intact. Any thoughts??
If he can’t blink, it is critical to use eye drops to avoid damage to the eyes from lack of lubrication. If he can blink, this is a good sign that the lack of facial animation will be temporary. Tincture of time is needed at this point. However, if the SLP wants to try some exercises, and since he can move his lips and jaw, this shows that the muscles of mastication are intact (trigeminal – cranial nerve 5) while the facial nerve (#7) has been traumatized, so working on opening and closing the mandible, moving it from side to side is recommended. I’m confused by your report that there is normal range of motion and strength of the lips but that they do not move. This doesn’t seem possible. If there is any lip movement at all, I recommend exaggerating /u/ and /i/ to mobilize the lips (if there is some movement there) which should help to reactivate the facial muscles. If however, the lips do not move, as also reported, then pursing them tightly and closing the eyes tightly can help to regain animation in the other facial muscles. So there are two choices: wait to see whether facial animation returns spontaneously, or exercise the facial sphincters (mouth and eyes) and hope for some carryover. As with other neurological problems, if the trigeminal nerve is intact, it can influence the facial nerve, so exercising the muscles of mastication by opening wide, biting down, and lateralizing can be tried, since there is reciprocity between these nerves; that is, one can take over some of the functions of the other and can be used to reactivate the other in therapy. I hope that these comments are helpful. Please let me know how this turns out. Thanks. Thank you Dr Mason. I apologize , I had an important typo- it should’ve said ‘normal strength/ROM of tongue and jaw’ but NO lip movement. This is such a strange presentation and it does not strike me as to be related to his CVA. Could it have been caused by the facial pressure of being face down on the floor for so long? Or something totally unrelated- but what ?? Intriguing case. Yes he is using eye drops and they are taping his eyes closed at night. Thanks for the added information. The facial nerve exits the skull at the foramen ovale. There is also a blood vessel exiting next to it. It could be that the position of the head on the floor has pinched the nerve as it exits at the base of the skull. My guess that this will spontaneously improve over the next few weeks.
