Peripheral facial paralysis

Peripheral facial paralysis causes asymmetry of the face affecting the upper and lower territories. Its management requires the completion of an initial clinical assessment in order to specify the topography, the severity of the involvement, the etiological nature and the possible complications. The knowledge and the mastery of the anatomo-physio-pathological bases makes it possible to understand the different clinical pictures. The rehabilitation must be started as early as possible, to accompany the various stages of sensitivo-motor recovery. It must be performed by a multi-disciplinary team consisting of a physical and rehabilitation doctor, a neurologist, an otolaryngologist, a plastic surgeon, a physiotherapist, a speech therapist and a psychologist whose role is to to help the patient to accept the self-image, to recover confi dence and self-esteem and to encourage the resumption of socio-cultural-professional activities. Review Article Peripheral facial paralysis Khalfaoui S*, El Abbassi EM Department of Physical Medicine and Rehabilitation, Military Instruction Hospital Mohammed V, Morocco Received: 07 May, 2019 Accepted: 16 July, 2019 Published: 17 July, 2019 *Corresponding author: Saloua Khalfaoui, Professor Assistant, Mohamed V University, Faculty of Medicine and Pharmacy of Rabat, Morocco, Tel: +212612608298; E-mail:


Introduction
Peripheral facial paralysis is a relatively common pathology requiring a specifi c diagnostic and therapeutic attitude. Its incidence is estimated at about 0.5 per 1000. The causes are varied but they are most represented by the idiopathic Charle Bell paralysis whose frequency can reach 50 to 70% of the cases [1].
Peripheral facial paralysis causes asymmetry of the face affecting the upper and lower territories. Its management requires the completion of an initial clinical assessment in order to specify the topography, the severity of the involvement, the etiological nature and any complications [2].
Faced with the functional and especially psychic repercussions, this pathology, often neglected, requires a comprehensive care involving physicians of different specialties: the otolaryngologist, the ophthalmologist, the neurologist, the psychologist and the physical physician and rehabilitation whose role is to direct the recovery of motor activity and avoid or at least minimize the sequelae [3].
This care must be put in place from the beginning to achieve a therapeutic project with setting objectives to be achieved and choice of means and appropriate techniques.

Anatomical reminder
Peripheral facial paralysis corresponds to the sensorymotor defi cit of the facial nerve (7th cranial pair).
This mixed nerve is composed of two roots: Motor, responsible for the innervation of the facial muscles.
Sensitive, sensory and secretory at the origin of the intermediate bronchus of Wrisberg.
The grouping of these roots is only part of the path of the nerve.
Thus, the facial nerve is essentially formed of motor fi bers and provides three functions: ¬ A motor function at the base of mimicry and motricity of the facial muscles.
¬ Sensitivo-sensory function at the origin of gustation and superfi cial sensitivity of the Ramsay Hunt area [4]. ¬ A vegetative or secretory function (para-sympathetic system) of the lacrimal and salivary glands [4].
The facial nerve originates within the protuberance, crosses the ponto-cerebellar angle in the direction of the internal auditory canal, with a path called "bayonet" in the rock to the stylomastoid foramen at the base of the skull and then branched into the parotid gland where it ends at the level of the facial muscles [5].

Positive diagnosis
Generally it is obvious when the patient presents himself in consultation with an asymmetry of the face, permanent opening of the eye of the affected side and important deviation of the mouth [6].
The functional signs of neurological order and the repercussion of these dysfunctions.

Physical examination:
At the inspection, the features of the face are deviated from the healthy side.
At rest, the face of the patient with peripheral facial palsy is characterized by: With the mimicry, all the signs are accentuated and the patient is incapable of infl ating the cheeks, to whistle or to blow correctly. (Figures 1,2) He fi nds an important gene for chewing with impossibility of closing the eye of the affected side.
The sensitivity of the cheek is preserved unless the injury is located above the tympanic cord where there is a disturbance of taste affecting the two previous shots of the tongue.
For the sensitivity of the Ramsay Hunt area, it is only exceptionally affected.
As for the vegetative function of the facial nerve, secretory dysfunction of the lacrimal and salivary glands depends on the lesion level. Muscular testing may be performed in addition to the clinical examination in order to assess the severity of the initial attack and to follow the evolution.
The most used is the Freyss muscle testing which tests ten medial and lateral muscle groups E: 0: no contraction, 3: normal contraction.
At the end of the testing, we obtain a score out of 30 giving an idea of the prognosis.

Para-clinical examination:
They are considered necessary for the topographical and etiological identifi cation of the lesion.

Radiologically:
Tomodensitometry of the rock: especially before the posttraumatic otological signs.
Magnetic resonance imaging: in front of signs of progressive installation and if elements in favor of a tumor etiology.
An otorhinolaryngological consultation is indicated in case of suspicion of pathology of the middle ear.

Represented mainly by:
Central facial paralysis: characterized by a predominant facial asymmetry in the lower territory, sparing the superior territory of the face. It is accompanied by neurological signs with dissociation of the automatic-voluntary motricity.
Constitutional facial asymmetry: eliminated at the end of a well conducted interrogation [6].

Complications and sequelae
Ocular complications: mainly represented by keratitis due to palpebral inocclusion with decrease or absence of lacrimal secretions exposing the cornea to this risk which increases from J15 of the motor defi cit. This underlines the interest of preventive treatment based on occlusive dressing and moistening eye drops.
• The syndrome of crocodile tears following food intake.

Therapeutic care:
The treatment consists of two parts: • Psychological: moral support and self-acceptance.

Rehabilitative management: [3]
Before establishing the therapeutic project, it is necessary to describe the broad assessment guidelines in rehabilitation that are based essentially on: Once the assessment is complete, the data will make it possible to set the objectives and choose the means adapted to each case.
Rehabilitation techniques differ according to the evolutionary clinical stage of paralysis, so we distinguish: [3]  Flaccid paralysis  Spastic paralysis  The operated paralysis At the stage of fl accid paralysis, which corresponds to the fi rst days of facial paralysis, the contralateral hemiface is favored with gentle massage, light movements and prevention of co-contractions.
From the onset of spasticity, the work is directed towards deep massages with control of abnormal movements, especially syncinesies that correspond to the co-contraction of different muscle groups during voluntary movements.
The feedback system keeps an important place in this step 1 [3].
As for the operated paralysis, the adapted protocol is chosen according to the surgical procedure. Thanks to the electrodes placed on the hemiface, we can determine the muscle to be treated.
It is a powerful technique for evaluating muscle strength before and after toxin injection, thanks to the stimulating effect that plays a signifi cant role in visual and audible feedback [13][14].
In the case of defi nitive peripheral facial paralysis, the surgical indication is posed in different modalities followed by a re-education aimed at  restore facial movements especially labial and palpebral  develop muscle automation  strengthen the cortical control of the smile.

Conclusion
Peripheral facial paralysis is a common reason for consultation in physical medicine and rehabilitation.
The knowledge and the mastery of the anatomo-physio-pathological bases makes it possible to understand the different clinical pictures.
The management and especially rehabilitation should be started as early as possible, to accompany the various stages of sensitivo-motor recovery. It must be performed by a multidisciplinary team consisting of a physical and rehabilitation doctor, a neurologist, an otolaryngologist, a plastic surgeon, a physiotherapist, a speech therapist and a psychologist whose role is to to help the patient to accept the self-image, to recover confi dence and self-esteem and to encourage the resumption of socio-cultural-professional activities.