Resident & Fellow Section

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Case Description

An 80-year-old man with HTN, HLD, and T2DM developed left facial droop and difficulty closing his eye over 1-2 days. Exam revealed inability to smile, raise his eyebrow, or fully close his eye (Video). Other cranial nerves and exam were normal. Brain MRI (to evaluate for brainstem stroke and structural lesions) and serum workup were negative, consistent with Bell’s palsy. The upper face receives innervation from bilateral hemispheres whereas the lower face is supplied by contralateral motor cortex only.¹ Lower motor neuron cranial nerve VII lesions demonstrate upper and lower facial weakness whereas upper motor neuron lesions spare the forehead. The House-Brackmann scale can be used to grade severity and guide management.²

References

1. Berkowitz A. Clinical neurology and neuroanatomy: A Localization-based approach. Lange McGraw Hill: 2017.

2. House JW, Brackmann DE. Facial nerve grading system. Otolaryngol Head Neck Surg. 1985;93(2):146-7. doi:10.1177/019459988509300202

Submitted by: Galina Gheihman, MD, Resident Physician, Mass General Brigham Neurology Program, Brigham & Women’s Hospital and Massachusetts General Hospital, Boston, MA; Baris Alten, MD, PhD, Resident Physician, Mass General Brigham Neurology Program, Brigham & Women’s Hospital and Massachusetts General Hospital, Boston, MA; Marcelo Matiello, MD, Assistant Professor of Neurology at Harvard Medical School and Massachusetts General Hospital, Boston, MA

Dr. Alten and Dr. Matiello report no disclosures. Dr. Gheihman is a Neurology Resident & Fellow Section Editorial Board Member, 2021-2024.