Case

A 34 year old patient comes to your clinic with paralysis of the left side of their face. You notice that their facial anatomy is asymmetrical with the right side showing facial expressions and the left side showing no movement or expression. The patient is drooling and is having trouble talking. When taking the patient history, they also report diminished food flavor and had parotid gland surgery in the last week as well as starting a new migraine medication along with recovering from the flu. A neurological assessment shows no other cranial nerve neuropathies.

Question 1/2 - What is the most likely diagnosis?

Click on your selected option(s) below  (correct = 1, possible = 3, over-thinking = 4+)

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Possible. A mass effect pressing on the motor nuclei controlling the muscles of facial expression could result in paralysis. However, the nuclei controlling the muscles of facial expression and the sense of taste are different, so such a mass would need to be quite significant to affect both nuclei and selectively shaped to affect only those nuclei without other symptoms.  

Possible! Sudden idiopathic paralysis of one side of the face is classified as Bell's palsy, however this is a diagnosis of exclusion where all other possible sources including trauma/surgery would need to be considered first. In this scenario there is a recent oral surgery that might be higher on diagnosis suspicion.

Incorrect. A heart attack results in epigastric, chest, or shoulder referred pain, not paralysis of the face.

Possible.  A stroke to the motor nuclei controlling the muscles of facial expression could result in paralysis. However, the nuclei controlling the muscles of facial expression and the sense of taste are different, so such a stroke would need to be quite significant to affect both nuclei and selective to affect only those (or two stroke events in short succession, an unlikely event).

Incorrect. This would result in respiratory distress, not craniofacial paralysis.

Incorrect. Seizures usually do not result in long term effects such as paralysis, they are acute incidents.

Correct! Given that the patient had parotid gland surgery in the past week, and the course of the facial nerve runs through the parotid gland, some post-surgical inflammatory responses are likely.

Direct nerve damage is also possible, particularly with deep lobe parotid surgery where the facial (VII) nerve is at elevated risk of injury. 

Incorrect. The trigeminal (V) nerve provides sensation to the face, not control of the muscles of facial expression.

Also the trigeminal nerve emerges from the supraorbital, infraorbital, and mental foramen to innervate the face. These foramen are closer to the midline than the laterally located parotid gland where the surgery occurred. Distal branches in the region of the surgery might be at risk, but not the main trunks of the trigeminal nerve.