Causes, Prognosis and Differential Prognosis, Ayurveda Understanding

Article by Dr Raghuram Y.S. MD (Ay) & Dr Manasa S, B.A.M.S

 In some neurological ailments, there may be facial deviation. For the reason that symmetry between each side of the face is misplaced, it’s known as ‘Facial Asymmetry’. It’s also known as Facial Droop.

Why it occurs – Facial asymmetry happens as a consequence of facial deviation, when the muscle groups on one aspect of the face get paralyzed or weakened. Facial deviation ends in asymmetry of face, drooping on the nook of the mouth or lack of ability to completely shut one eye.

Causes – Facial Asymmetry usually happens as a consequence of both –

1. Higher Motor Neuron Lesions (UMN) or
2. Decrease Motor Neuron Lesions (LMN)

The opposite widespread circumstances which trigger facial asymmetry are (generally identified) –

1. Bell’s Palsy – the most typical trigger for facial deviation (additionally a LMN Lesion)
2. Stroke – a life-threatening situation which might trigger facial deviation (additionally a UMN Lesion)

The primary purpose shall be to differentially diagnose these circumstances and label them correctly, particularly UMN and LMN lesions.

Differentiating the circumstances inflicting Facial Asymmetry

To begin with allow us to begin with differentiating UMN and LMN Lesions, which is essential on this route in order to rule them in or out.

Do Not Miss the FOREHEAD – In differentiating between UMN and LMN Lesions inflicting facial deviation, it is rather essential to start out with the ‘FOREHEAD’. This ‘Brow Take a look at’ rapidly helps us to slim down the reason for facial deviation.

Golden Rule – ‘LOOK AT HOW MUCH THE FACE IS AFFECTED’

1. UMN Lesions – Central Causes – FOREHEAD IS SPARED

There’s deviation of solely the LOWER HALF of the face whereas the brow often nonetheless strikes.

Cause – The higher half of the face receives the nerve alerts from each side of the mind.

To maintain it brief – Brow is unaffected. There’s paralysis and deviation of the decrease half of the face.

UMN Causes to look out for – They’ve their origin within the mind, often indicating a CNS (central nervous system) challenge. These circumstances will current with no or minimal facial deviation (asymmetry) or weak point.

The UMN causes to think about facial asymmetry are –

1. Stroke / CVA (Cerebrovascular accident) – There is no such thing as a brow weak point. Facial droop in stroke is sudden. It’s typically accompanied by arm or leg weak point, problem in speech (slurred speech) and lack of stability.
2.   Transient Ischemic Assault (TIA) – The signs are similar to a stroke however they resolve inside 24 hours or so.
3. A number of Sclerosis (MS) – Marked by intermittent episodes of facial weak point triggered as a consequence of central pathways being affected by demyelinating plaques and is commonly accompanied by numbness or imaginative and prescient issues.
4.   Intracranial Tumors or Lesions / Mind Tumor – The tumors compress the motor cortex or brainstem. On this, there could also be a sluggish onset of facial weak point. Related options embrace stability points, imaginative and prescient modifications or power complications.

2. LMN Lesions – Peripheral Causes – FOREHEAD and ENTIRE FACE (One Aspect) is AFFECTED

There’s paralysis and therefore deviation of the entire ONE SIDE of the face together with the brow.

Cause – Your entire identical aspect of the face is managed by LMN.

To maintain it brief – Brow is affected. One half of the face together with the brow of that aspect are paralyzed and deviated.

LMN Causes to look out for – They have an effect on the facial nerve after the nerve has left the mind stem. These circumstances will certainly current with facial deviation or weak point.

The LMN causes to look out for in facial asymmetry circumstances are –

1. Bell’s Palsy – That is the most typical (60-75% of circumstances) trigger for facial deviation / asymmetry. The illness is characterised by sudden onset of unilateral facial paralysis. The situation is idiopathic. There’s speedy onset and the signs peak often inside 48 hours.
2.   Ramsay Hunt Syndrome / Herpes Zoster Oticus – This situation is brought on by reactivation of shingles virus. The doctor must look out for painful blisters within the ear canal or mouth roof. The situation presents with extreme ache within the ear, a vesicular rash within the ear canal or mouth and in addition points with listening to and stability.
3. Lyme Illness – The trigger is a ‘tick chunk’ (Borrelia burgdorferi tick). It clearly begins off with a rash (bull’s eye rash) which is adopted by facial palsy. The palsy could be bilateral – facial diplegia.
4.   Tumors – Primarily look out for a parotid gland tumor or acoustic neuroma because the chief trigger. There’s sluggish and progressive weak point of 1 aspect of the face and is commonly accompanied by a palpable lump close to the jawline. Localized twitching or listening to loss might also be related.
5. Trauma / Iatrogenic – Direct damage to the face as happens in accidents or a temporal bone fracture are sometimes causal. Nerve harm from dental work or surgical procedures together with parotid gland or mastoid are additionally causa.

Different Uncommon Systemic and Autoimmune Causes

1. GBS (Guillain Barre Syndrome) – Bilateral facial paralysis is a characteristic on this autoimmune dysfunction. The illness has a speedy onset and infrequently begins off with leg weak point. The illness is progressive and would contain progressive symmetrical limb weak point, areflexia. 
2. Sarcoidosis – It’s an inflammatory illness which may have an effect on the facial nerve. It could actually trigger bilateral palsy or parotid enlargement (Heerfordt Syndrome) when the illness impacts the facial nerve.
3. Melkersson Rosenthal Syndrome – It’s a uncommon genetic situation which causes recurring facial palsy. There might also be related lip swelling and a fissured tongue. MRS Triad consists of – recurring facial palsy, fissured tongue and facial / lip swelling.
4. Infections Meningitis or Otitis Media – On this situation, there may be direct unfold of bacterial or viral infections affecting the nerve throughout the temporal bone.

Alarming Indicators

One ought to contemplate facial deviation as a medical emergency when it’s accompanied with different warning indicators as beneath talked about (any of them( –

–        Limb weak point

–        Numbness

–        Problem in strolling

–        Slurred speech

–        Concussion

–        Blisters across the ear

–        Extreme vertigo

–        Double imaginative and prescient

Diagnostic Strategy

Correct and well timed analysis could be very important in facial deviation circumstances since it could point out a medical emergency or a severe systemic an infection. It shall be assessed with the assistance of a number of of the beneath talked about diagnostic instruments

–        Neurological examination – an intensive take a look at of cranial nerves with particular emphasis in the direction of seventh cranial nerve i.e. facial nerve

–        Otoscopy – for vesicles (to rule out Ramsay Hunt Syndrome)

–        Imaging – when the trigger shouldn’t be clear and if there may be sluggish development of weak point over many weeks or when a tumor / central lesion is suspected as causal for facial deviation, MRI or CT scans are steered

–        Blood Work – is finished to check for inflammatory markers, Lyme antibodies and HIV and so forth.

Circumstances described in Ayurveda depicting ‘Facial Deviation’ or ‘Facial Asymmetry’

Facial Deviation or Facial Asymmetry, in keeping with Ayurveda is a situation brought on by aggravated Vata. It’s also a Vata Nanatmaja Vyadhi – a particular situation brought on by aggravation of solely Vata.

Ardita, a situation described in Ayurveda treatises resembles the outline of facial paralysis / palsy or Bell’s Palsy whereby facial deviation, asymmetry or crookedness of the face (vakram bhavati vaktra ardham) has been clearly talked about amongst the signs.

One other situation which must be thought of herein is Pakshavadha or Pakshaghata. Although Pakshavadha describes hemiplegia, the weak point of half face and its deviation too shall be thought of. The outline of Pakshavadha additionally consists of Ekanga Vata and Sarvangna Vata (aggravated vata affecting half or full physique respectively), that are additionally stated to be the synonyms of Pakshavadha.

Subsequently, this Ardita-Pakshavadha situation in totality describes each single situation described within the differential analysis of facial deviation above.

Associated Studying 

Paralysis – Ayurveda Understanding – Straightforward Ayurveda Article

Charaka Samhita – Vata Vyadhi Chikitsa by Straightforward Ayurveda

Facial Paralysis – Straightforward Ayurveda Article

Madhava Nidana – Vata Vyadhi Nidanam

AIAPGET Questions

1. Facial deviation related to lack of ability to wrinkle the brow suggests:

1. Higher motor neuron lesion
2. Decrease motor neuron facial palsy
3. Trigeminal neuropathy
4. Glossopharyngeal palsy

Reply: B. Decrease motor neuron facial palsy

Clarification: Bell’s palsy impacts your entire ipsilateral face together with brow muscle groups.

2. Which of the next signs is least probably in Ardita?

1. Deviation of Face
2. Speech Problem
3. Deviation of nostril
4. Full lack of consciousness

Reply: D. Full lack of consciousness

Clarification: Consciousness stays intact in Ardita.

3. In fashionable neurology, preservation of brow actions with facial deviation signifies:

1. Bell’s palsy
2. LMN facial nerve lesion
3. UMN lesion above facial nucleus
4. Trigeminal neuralgia

Reply: C. UMN lesion above facial nucleus

Clarification: Brow receives bilateral cortical innervation.

4. A affected person presents with facial asymmetry, hyperacusis, lowered lacrimation, and lack of style in anterior 2/3 of tongue. The lesion is probably in:

1. Trigeminal nerve
2. Facial nerve proximal to chorda tympani
3. Hypoglossal nerve
4. Oculomotor nerve

Reply: B. Facial nerve proximal to chorda tympani

Clarification: Facial nerve carries style fibers and provides stapedius.

5. Which Nidana is particularly talked about for Ardita in classical texts?

1. Extreme publicity to chilly wind
2. Extreme blood loss
3. Extreme fasting alone
4. Extreme sleep alone

Reply: A. Extreme publicity to chilly wind

Clarification: Sheeta, Ativata-sevana, and publicity to chilly are essential Vata-provoking causes.

6. Facial deviation occurring together with contralateral hemiplegia is classically suggestive of:

1. Bell’s palsy
2. Remoted facial neuropathy
3. Central facial palsy as a consequence of stroke
4. Trigeminal neuropathy

Reply: C. Central facial palsy as a consequence of stroke

Clarification: UMN lesions typically produce facial weak point with hemiplegia.

7. Essentially the most applicable Ayurvedic Panchakarma process in power Ardita dominated by Vata-Kapha is:

1. Virechana solely
2. Raktamokshana solely
3. Nasya Karma
4. Tikta Kshira Basti solely

Reply: C. Nasya Karma

Clarification: Nasya is taken into account the prime remedy for ailments above the clavicle (Urdhvajatrugata Vikaras), together with Ardita.

8. Intermittent episodes of facial weak point in A number of Sclerosis is attribute of –

1.   Higher Motor Neuron Lesion
2.   Decrease Motor Neuron Lesion
3.   Each
4.   None

Ans – Higher Motor Neuron Lesion.

Clarification – The involvement of the brow is spared.

9. Facial deviation in Ramsay Hunt Syndrome is attribute characteristic of –

1.   Decrease Motor Neuron Lesion
2.   Higher Motor Neuron Lesion
3.   Each
4.   None

Ans – A. Decrease Motor Neuron Lesion.

Clarification – The brow can be concerned.

10. When facial deviation happens following surgical procedure of parotid gland, it displays –

1.   Higher Motor Neuron Lesion
2.   Decrease Motor Neuron Lesion
3.   Each
4.   None

Ans – B. Decrease Motor Neuron Lesion.

Clarification – The brow can be concerned.