Bilateral weakness of facial muscles: causes, symptoms, diagnosis

The bilateral weakness of the facial muscles, developed simultaneously or sequentially, is not common, but almost always serves as a cause for diagnostic doubt when trying to establish its cause.

I. Bilateral lesion of the trunk of the facial nerve (diplegia facialis)

1. Guillain-Barre syndrome (with ascending flow) and other polyneuropathies
2. Sarcoidosis (Heerfordt's syndrome syndrome)
3. Basal meningitis (carcinomatous, leukemic, etc.)
4. Gilt and other common infections
5. Lyme disease
6. Botulism (rarely)
7. Tetanus
8. HIV infection
9. Syphilis
10. Rossolimo-Melkerson-Rosental syndrome
11. Craniocerebral injury
12. Paget's disease
13. Hyperostosis cranialis interna
14. Bell's idiopathic paralysis
15. Toxic forms of facial nerve neuropathy.

II. Bilateral lesion of the nuclei of the facial nerve

1. Poliomyelitis (rare)
2. Congenital paralysis with Mobius syndrome
3. Bulbospinal neuronopathy
4. Tumors and hemorrhages in the area of the Varoliev Bridge

III. Muscular level

1. Myopathy
2. Myotonic dystrophy

I. Bilateral lesion of the trunk of the facial nerve

The paralysis of muscles innervated by the facial nerve can be bilateral, but it rarely develops on the left and right half of the face at the same time. The last variant (diplegia facialis) is most often observed in the ascending course of Guillain-Barre polyneuropathy (Landri's paralysis) and appears against the background of generalized tetraparesis or tetraplegia with sensitive impairments in the polyneuropathic type. Dipledia facialis is described in Miller Fischer syndrome, idiopathic cranial polyneuropathy, amloidosis, diabetes mellitus, multiple sclerosis, pseudotumor cerebri, porphyria, Wernicke's encephalopathy, Bell's idiopathic paralysis, hyperostosis cranialis interna (hereditary disease manifested by thickening of the inner skull plate of the skull). Sometimes bilateral lesion of the facial nerve occurs in sarcoidosis (Heerfordt syndrome) and is accompanied by other somatic symptoms of sarcoidosis ("uveoparotid fever"): the damage of lymph nodes, skin, eyes, respiratory organs, liver, spleen, parotid salivary glands, bones and (rarely) other organs . From the side of the nervous system, it is possible to involve other cranial nerves and membranes. In the diagnosis, the histological examination of the biopsy specimen of affected tissues is important.

Other possible causes of bilateral facial nerve lesions: nodular periarteritis, giant cell arteritis, Wegener's granulomatosis, systemic lupus erythematosus, Sjogren's syndrome, Stevens-Johnson syndrome, which is based on an inflammatory febrile illness of the skin and mucous membranes.

In the genesis of bilateral lesion of the facial nerve, the basal meningitis of another etiology (carcinomatous, leukemia, tuberculosis, cryptococcal) is also important, in the recognition of which, in addition to the clinical picture, an important role is played by the cytological examination of the cerebrospinal fluid; encephalitis (including trunk encephalitis); otitis media. As known causes of bilateral lesion of facial nerves, malaria, infectious mononucleosis are described; herpes zoster and herpes simplex, syphilis, parotitis, leprosy, tetanus, mycoplasmic infection, and more recently - HIV infection.

Lyme disease (borreliosis) as a cause of bilateral lesion of facial nerves is well studied. It is characterized by early skin manifestations (characteristic of erythema), arthropathy, polyneuropathy, lymphocytic meningitis and cranial nerve damage, especially the involvement of the facial nerve. Outside the epidemiological situation, a diagnosis can be difficult.

The Rossolimo-Melkerson-Rosenthal syndrome, which is characterized by a triad of symptoms in the form of recurrent paralysis of the facial nerve, edema of the face in the oral region (cheilitis) and folded tongue (the latter symptom is not always present), is also sometimes manifested by bilateral involvement of the facial nerve.

Craniocerebral trauma (fracture of the temporal bones, birth trauma), as the cause of bilateral paralysis of the facial nerve, for obvious reasons rarely serves as a reason for diagnostic doubts.

In the diagnosis of Paget's disease as the cause of bilateral facial nerve damage, radiologic examination of the bones of the skeleton, skull and clinical manifestations (asymmetric arcuate deformities of the bones of the skeleton, limitation of mobility in the joints, pain syndrome, pathological fractures) is crucial. In addition to the facial nerve, the trigeminal nerve, auditory and optic nerves are often involved; possibly the development of hypertension syndrome.

The use of ethylene glycol (a component of antifreeze) with a suicidal purpose or with alcoholism can also lead to bilateral weakness of facial muscles (permanent or transient).

II. Bilateral lesion of the nuclei of the facial nerve

Poliomyelitis rarely causes diplegia of facial muscles. If in adults bulbar poliomyelitis is almost always accompanied by paralysis of the extremities (bulbospinal poliomyelitis), children may have isolated lesions of bulbar motor neurons. Cranial nerves most often suffer from facial, glossopharyngeal and vagus nerves, which is manifested not only by the weakness of the facial muscles, but also by the difficulty of swallowing and phonation. The serological test confirms the diagnosis.

There is also a congenital diplegia facialis, which is accompanied by a converging strabismus (paralysis of not only the facial but also the distracting nerves). The basis is the underdevelopment of motor cells in the brain stem (Mobius syndrome). Some forms of progressive spinal amyotrophy in children (Fazio-Londo disease) lead to a two-staged paralysis of facial muscles against the background of other characteristic signs of this disease (bulbospinal neuronopathy).

Other causes: glioma of the variola bridge, neurofibromatosis, metastatic and primary tumors, including shell tumors, hemorrhage in the region of the variolium bridge.

III. Two-sided weakness of facial muscles, caused by a primary lesion of the muscular level

Some forms of myopathy (fazio-skapulo-humeralnaya) are accompanied by the development of weakness of the facial muscles from two sides against a background of a more common atrophic paresis (in the shoulder region). With myotonic dystrophy, facial muscles are involved in the pathological process along with the defeat of other (not mimic) muscles: lifting eyelids, as well as chewing, nodding and limb muscles. If necessary, EMG and a biopsy of the affected muscles are used for diagnostic purposes.

Diagnostic studies with bilateral weakness of facial muscles

1. Clinical and biochemical analysis of blood.
2. Analysis of urine.
3. CT or MRI.
4. Radiographs of the skull, mastoid process and pyramid of the temporal bone.
5. Audiogram and caloric assays.
6. Investigation of cerebrospinal fluid.
7. Electrophoresis of serum proteins.
8. EMG.

You may need: chest x-ray; serological tests for HIV infection, syphilis; biopsy of muscle tissue, consultation of an otiatrist and therapist.