2023-08-15 10:17:47
Facial paralysis is relatively common, with various differential diagnoses including infections and tumors. While Bell’s disease is the most common cause, there are exceptions, as published in the journal British Medical Journal.
A woman in her early 30s was referred to an otology clinic for progressively worsening left-sided facial paralysis. Two weeks before the onset of paralysis, she heard a loud cracking sound when opening her mouth to drink, then felt sharp pains on the left side of her face and neck. The suspicion of a salivary gland infection led his GP to prescribe him antibiotics, but his symptoms did not improve. A left-sided facial paralysis eventually developed and an external ENT specialist treated her with oral steroids and valaciclovir for two weeks before referring her to the clinic.
The patient presented with trismus, tenderness in the left retromandibular area and pain when she opened her jaw more than 2 to 3 cm. Examinations revealed no signs of inflammation or sialadenitis, and his parotid glands were not palpable. Otoscopic examination revealed normal ear canals and eardrums. An audiogram and Weber and Rinne’s tests all returned normal results. The House-Brackmann facial nerve grading system indicated left-sided grade IV, signifying moderately severe dysfunction. Serological tests for IgG anti-varicella zoster virus (VZV) antibodies, IgM anti-VZV antibodies and anti-VZV antibodiesBorrelia burgdorferi were all negative. A blood test revealed an elevated white blood cell count. A CT scan revealed a left styloid fracture near the stylomastoid foramen, which may have resulted in compression of the facial nerve. Magnetic resonance imaging confirmed inflammation in the same area, but showed no signs of tumors.
The patient received corticosteroids and valaciclovir. She showed significant improvement in left-sided facial asymmetry one month later. Although she still had pain in the left infra-auricular region, she might yawn and eat without discomfort. Left facial nerve function improved to House-Brackmann grade I.
Discussion
Eagle syndrome results from elongation of the styloid process or calcification of the stylohyoid ligament, which results in compressions and pain triggered by movement of the neck. The classic type is manifested by the sensation of a foreign body in the throat and difficulty in swallowing, accompanied by dull pains that intensify during swallowing and yawning. It is an intermittent compressive neuropathy of cranial nerves V, VII, IX and X, the glossopharyngeal nerve being the most affected, which must be distinguished from neuralgia of the glossopharyngeal nerve.
Carotid-like Eagle syndrome involves compression of the major blood vessels in the neck. If the internal carotid artery is involved, patients may experience neurological symptoms such as dizziness, syncope, and Horner’s syndrome. Cases of sudden death have also been reported. Compressions of branches of the external carotid artery cause ipsilateral facial and neck pain. Compression of the internal jugular vein (which is not a true Eagle syndrome) can lead to headaches and venous hypertension syndromes. Exacerbation of symptoms may occur with contralateral head rotations because the internal carotid artery and internal jugular vein are medial to the styloid process.
Max Heiland, from the Charité Oral, Maxillofacial and Facial Surgery Clinic, recommended Consider Eagle’s syndrome for patients with chronic pain in the jaw joint and/or upper neck that is accompanied by swallowing difficulty and globus sensation. A panoramic X-ray is often sufficient to establish the diagnosis, particularly when the triad of symptoms consists of peri-angular pain, foreign body sensation in the throat, and difficulty swallowing. The angulation of the styloid process, not just its length, is important for clinical symptoms. Conservative treatments involve first-line analgesics such as nonsteroidal anti-inflammatory drugs. In addition, alternative strategies such as the combination of anticonvulsants, antidepressants and local injections can be considered. In most cases, surgical shortening of the styloid process can be performed intraorally.
This article was originally published on Univadis Germany.
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