A WOMAN WITH PERIPHERAL
BILATERAL PARESIS' OUTCOMES OF THE FACIAL NERVE FROM HERPETIC NEURITIS, TREATED
BY ANTISTRESS THERAPY. (Updated on
November 2005).
Renato COCCHI, neurologist and medical
psychologist.
(An other treatment case of facial paralysis' outcomes)
Summary.
This article reports the case history of
a 28-years woman, jazz singer, who about two years and half ago, had a
peripheral paresis of the cranial nerve VII, or facial, from Herpes Simplex.
The medical history from the onset of the paralysis to the moment of the first
consultation has annotation. There she showed paretic results, as spasms and
dystonias, perhaps even of central origin, stress symptoms, mood troubles,
headaches, among them back of the ear headache, and troubles of the half-brain
dominance. Being treated with antistress and antidepressant drug therapy for
about 21 months, the whole frame is improving, the outcomes of the facial
paresis too. In particular, she reported easy activity as a jazz singer.
Key words: Facial nerve, paralysis,
Herpes Simplex, outcomes, paresis, stress, depression, half-brain dominance,
drug therapy.
Drug modulation of stress reactions
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In 2003 I posted on Internet my first case
of idiopathic paralysis of the VII cranial nerve, or facial, whose paretic
outcomes I treated by antistress drugs. (Cocchi 2003).
A young woman came to consultation with
outcomes of facial nerve peripheral paralysis from a post-herpetic infection
(Herpes Simplex). Three months later I started the report of this new case,
even because of its complexity. I have to say at once that only the stress
symptoms' presence and depression led me to think the possibility of a
therapeutic attempt encompassing the same paretic outcomes.
The case history.
F, of twenty-eight years at the first
consultation, shop-assistant, and jazz singer.
August 2000. A neurologic visit reports of a
bilateral deficit of the closing of eyelids, bilateral paresthesias of the
face, a bilateral deficit of the closing of the mouth. She advised to enter the
hospital for a bilateral deficit of the VII cranial nerve with the acute onset.
Same day: She entered the neurology
department. Remote pathological case history: Five years before, following a
road accident, she had skull trauma not accompanied by any bone damage and/or
by the conscience loss. Brain CAT was normal, but "whiplash " to the
cervical rachis and right femur fracture. From then she suffered from cervical
pain episodes.
Recent pathological case history: Three
weeks before she had a fever (bodily temperature up to 39°C) lasting about a
week, with pharyngodiny, cervical lymphoadenopathy and occipital and vertex
areas' headache. She had trihydrate amoxicilline, hanging after some day
because the appearance of an oral candidosis.
The patient reported hypoesthesia of the
oral mucous membranes and dysgeusia. From the end of July she had intense
painful reheightening to the pre- and behind-auricular regions, mainly in the
left side, with slight persistent fever.
Since two days she reported appearance of
gradual hyposthenia of the facial muscles, in particular of the mandibular
arcade, with difficulty of the opening and closing of the mouth. Moreover, she
complained of dysphagia, nausea feeling, and occipital and vertex pulsating
headaches.
Objective neurologic examination at the
entry: She shows a bilateral deficit of facial nerve, peripheral type, but no
other pathological neurologic reliefs.
Brain CAT in the norm, spinal fluid in the
norm, the Blink Reflex in the norm too.
Treated initially with immunoglobulins in
high intravenous injection dosing, then, when serodiagnosis done, she had
therapy with acyclovir.
ENMG in the same day: Signs suggesting an
interruption of the peripheral conduction of the facial nerve to the exit from
the style-mastoid foramen, bilateral, involving all the branches; the findings
of muscular derivation not suggest degeneration elements of the muscular
fibres; Findings of motor and sensitive conduction as well as "H"
answers in the norm.
ENMG, seven days later: As compared to the
preceding examination, it currently underlines the sign's presence of a
neurogenic trunk lesion of the facial nerve, in both sides, with maintenance of
the conduction of part of the left fibres; afferent times of conduction are in
the norm; This frame is related to a bilateral axonal, more relevant in the
right side.
During the hospitalization the mastication,
the closing of the eyelids fissure, and of the labial fissure, mainly the left
one, improved.
Hospital exit fifteen day after the entry
with diagnosis of facial dyplegy from herpetic neuritis, with positive serum
diagnosis for Herpes Simplex 1 and 2 (positive IgG and IgM). The facial paresis
is in initial recover. Home drug treatment with acyclovir, B1-B6-B12 vit.s, C
vit. and gabapentin.
November 2000: There is till positiveness of
HSV antibodies (1-2) IGM and IgG.
February 2001: Negative HSV antibodies (1-2)
IgM; Positive HSV antibodies (1-2) IgG.
April 2001: EMG: There are compatible
findings with not recent neurogenic pathology in the right frontal area. Normal
the bilateral findings of the orbicular muscles of the eye and of the mouth.
June 2001: HSV antibodies (1-2), negative
IgM. HSV antibodies (1-2), positive IgG.
March 2002: Clinical neurophysiology: The
report states of stabilized outcomes of right and left facial deficits, with
errors of the re-innervation and facial pathological synkinesises.
July 2002: Neurologic consultation: Dyplegy
outcomes of the facial nerve with right half-spasm; in the right side both the
deficit of the facial nerve and the half-spasm improved. The patient reports
tension and pain to the temporal-mandibular articulation with even pain to the
cervical-dorsal area, due to probable dental bad occlusion.
July 2003: Both sided EMG on the orbicular
muscles of the eye and of the mouth. The results are compatible with suffering
neurogenic outcomes in the examined districts to peripheral innervation of the
cranial nerve VII bilateral, in particular to the right side. There are also a
contemporary unintentional synkinetic post-paralytic activity eye-mouth and
vice versa, bilaterally.
January 2004: Ophtalmologist' consultation
for visual darkening in the right eye and dizziness: He observed light
hyposthenia of the orbicular muscle of the right eye.
February 2004: The first consultation: She
suffers from bilateral outcomes from a paralysis of the facial nerve ( VII
cranial nerve) from herpetic neuritis (Herpes Simplex). She has spasms of the
orbicularis muscle of the eye, of the masseter muscle and of the orbicularis of
the mouth. Unintentional synkinetic post-paralytic activity eye-mouth and vice
versa, occur even bilaterally.
The paralysis had its onset in the summer
2000, with modest fever (39°c).
She can wrinkle her forehead, but with some
work. There is a modest presence of the phenomenon of Bell. She can sing, but
she do it with tiredness and has some difficulty to climb up the acute notes.
At the specific examination, she has some pain at the exit of the roots of the
facial to the supraciliary point, to the point nose-cheek, to the mandibular
point, of both side, but more in the right one. She has left ear hyperacusia.
The right nose-cheek fold is more evident, but even here reduced. The right
mouth fissure is reduced. There is some modest difficulty to show the teeth.
She can to puff out her cheeks enough well. Ageusia is limited to the anterior
third of the tongue.
Problems of half-brain dominance: To the test: Which is the opposite of Red colour?
she answers Green. She has always The Contrary Mary character. Frequently, she does
bad dreams; She has the onset of bad thoughts against herself, which she feels
as extraneous to her personality.
Stress symptoms: She bears badly the light, the noise and the
confusion. Intrusive thoughts are often present, and disbandment feeling or faint
feeling. She has vertex, or nape of the neck, or beyond the right ear
headaches, which all are increasing in the premenstrual period. She suffers
much the damp, and more the cool than the heat, has nighttime bruxism and
memory and concentration troubles.
Mood: A masked depression appears, with some abulia, surely in a share as
reaction to her disability. She is doing better in the afternoon.
She has feeding problems attributed to food
intolerance: She doesn't appreciate sweet things, likes the meat broth, does
not intake milk but some cheese, needs vegetable and yields.
Fat hairs, normal menses, normal bowel
function, no colic aches were reported. She sleeps well, doesn't talk when
sleeping, does not slobber during the sleep, does not wake up tired and needs
to have breakfast at once.
Starting therapy (daily doses, by the oral
via): Glutamine 125mg; pyridoxine 75mg; carbamazepine 100mg;
5-hydroxytriptophan 50mg; bromazepam 0.9 mg.
March 2004. The first checkup, after one
month of drug therapy. She refers that she is doing better. In the first days
of the therapy she had some tachycardia.
Outcomes of the facial paralysis: when she is nervous, she has a tic at the right
eye. The mandibular tension reduced, the emisson of her voice when she is
singing is going better. The tone of the mimic muscles is more suitable. At the
beginning of the drug therapy she had fewer headaches, then they redid, mainly
those behind her ear.
Troubles of half-brain dominance: The ugly dreams increased. The intrusive thought perhaps
reduced.
Stress symptoms: Towards evening she does more labours to control
everything. She bears better the light and the confusion. The premenstrual
period was less painful. She listed in a gym, but she feels muscular pain and
headache after the physical effort. The damp troubles her as before this
therapy and she became more sensitive to the cold. He hairs are less fat. In
the mornings she has less mandibular pain [following less night bruxism?].
Feelings than disbandment are fewer and not more feelings of fainting. Now she
is eating to more sweet things.
Mood: The mode improved, mainly in the mornings, and she wants more to do,
but she has sudden mood changes. Her memory is working better and there are
fewer food problems.
The surrounding persons observed her
positive change.
Therapeutic variation (daily doses, by the
oral via): Glutamine 250mg; Carbamazepinaa 200mg; amitriptyline 10mg;
Bromazepam 1mg.
May 2004: The second checkup, after three
months from the starting of the drug therapy. She is doing enough well.
Outcomes of the facial nerve paralysis: When singing, she succeeds better in the agility
passages, has more voice volume and tires of less. The singing teacher was aware
that the voice is more open and her pupil increased the extension towards the
acute notes. The right mouth spasms did not change and they transmitted to the
relative eye orbicular muscle.
She wrinkles her forehead in normal way, but
has fewer headaches behind her ear, and still left hyperacusia. The pain
sensation in the exit points of the facial branches of the VII nerve limited to
the left superciliary point, to the right nose-cheek point and bilaterally to
the mandibular points. Now, the right nose-cheek furrow is more evident. She
believes that the ageusia of the anterior third of the tongue reduced. She says
that the inferior lip is "more elastic." The right mouth fissure is
still open, but less than before. The unintentional post-paralytic synkinetic
eye-mouth activity and vice versa, appear to limit to the right side.
Troubles of the half-brain dominance: She is still the contrary Mary, but has fewer bad
dreams, although they are more vivid. There are fewer bad thoughts towards
herself. Her head has less plenty of intrusive thoughts. Sometimes it happens
to her to say the opposite.
Stress symptoms: She had a stressful period, with symptoms worsening,
following the death of a beloved friend. She has more endurance, feels the
weather changes and is still dyslexic. The headache fits reduced, but they are
still worsening in the premenstrual period, even there in a lesser way. The
bruxismo reduced too. When tired, she has lump in to the throat. Feelings than
disbandment disappeared. Now, she has less difficulty of concentration, and
sees better the problems, as for an example, the harmonic relationships in a
musical passage. To eat more sweet things increased.
Mood: More serene, in the mornings she is well off. She eats less cheeses.
Her memory is always a little fragile.
Other: She is fatten up 4kg, sleeps well, her bowel functon runs regulated.
Prescribed therapy (daily doses, by the oral
via): Glutamine 125mg; S-adenosil]-l-methionine 200mg; Pyridoxine 75mg;
5-hydroxytriptophan 50mg; Bromazepam 1mg; Carbamazepine 300mg; Amitriptyline
10mg.
First days of September 2004: This is an
e-mail sent by the patient, with a report of these last three months of drug
therapy.
For the physical strength, it is much
improved, either in the sport, in the job, and in all that it relates to simple
and usual actions of every day.
It is as every part of my body, little by
little, by short steps, was taking confidence with the various daily actions
and taking awareness of its real strength.
This for what concerns my physical
strength but as for the coordination of the facial muscles, it is much improved
that too, with fewer spasms. I succeed to smile more in horizontal and I feel
me more free and more tonic as for the lips and around them. My words'
articulation improved, and now I can pronounce better the [phonemes] (p) and (f) and when I smile, even the
right eye is less closing.
The only problem of the facial paresis
outcome is that I have still feelings of constraint on the face, as if had a
mask, which presses on my face.
My memory improved a few, while I have
still that yelding feeling and of little balance, but only when I am under
emotional tension (like on stage and when I am afraid of make a mistake).
Now I pass to the more complicated side,
the emotional one.
In the morning of the last four days, as
mentioned you by phone, I wake me up much tired and with little stimuli. I feel
that I would to do, but feel me with my strength consumed.
I have problems of words'articulation,
and some pain under and over the ears. What is more, I have fever reflexes [?? Less ability to react?] and my ears seem
stuffed with wadding.
I am pleased about certain short steps I
have done in these months, even for the better trust in myself, the safety and
the daring. Nevertheless, I feel me always in a danger as if there it were
always somebody ready to judge me and to laugh at me.
By comparing to my past, now I succeed to
rationalize better the situations and I don't think at once in negative, even
if I do much work.
I feel me always under pressure, and when
I feel me obliged to the others and to myself, I perceive a strong pressure
into my head. There is a fixed point that provokes me enormous confusion, even
if this confusion has slightly attenuated.
The aching point is that I cannot throw
me in the things and I maintain always the distances. So, when I step onto the
stage, I cannot express myself as I would like. I don't know because I am
afraid that the public may read my state and my difficulties . . . ..
It is not simple to explain this point,
but make me free from this oppression feeling, of either mental and physical
closing. I need to take back, step by step, the strengths that are up to me and
that serve to give dignity to my person. So, I don't want to feel me as
inferior to the others or limited, against my great desire I have to doing well
in this world, as my greater aim.
Excuse me if I dwelt. I did not want to
waste your time, but you are the only person that possesses the useful
knowledge to understand cases like theses. [This last sentence has much of the exaggeration!].
End Septmber 2004, third checkup after seven
months of drug therapy.
She had a modest regression of some symptoms
in the September month, probably concerning the seasonal change. Moreover, she
took the pyridoxine only every two days, and fat hairs returned to her.
Results on the outcomes of the facial nerve
paralysis:
- Pain after her ear not varied in the last
four months;
- Hyperacusia for noise much improved;
- Wrinkling of the forehead nearly to
normalize;
- Difficulty to lift the eyebrows: It is
only evident to left side, and lately it worsened a little;
- Narrow palpebral fissure: It remains only
to the right side, and evident when she is under stress;
- Pain to the pressure to the superciliary
points: It is absent in both sides;
- Pain to the pressure to the nose-check
points: Present in the left side, but the pressure works against an internal
metallic plate;
- Pain to the pressure to the mandibular
points: It is absent in both sides;
- Sunken nose-check plica: It is moderately
present to the right side when mimic muscles are at rest;
- Falling of the mouth fissure, already
missed, but it came back the last month;
- Ageusia of the anterior third of the
tongue: Not more felt;
- Mouth-eye synkinesises: They are not
present in the left side, they resurfaced in the right side when smiling;
- Tremors to the orbicularis of the right
eye and of the right one of inferior lip: They resurfaced under stress, or
increased during the last month;
- Difficulty to puff out one's cheeks:
Improved, she succeeds also to whistle, even if with weak strength.
The feeling of a mask pressing on her face
worsened since the beginning of September. She does some labours to lift the
cheekbones when singing, more the right one. The vowel issue improved. Many
other persons realized her improvements: Her boyfriend, her family, her
friends, work colleagues. Now she has more self-confidence.
Therapeutic variation (daily doses, by the oral
via): Pyridoxine 75mg; Carbamazepina 400mg; Biotin 2.5mg; Bromazepam 1.5mg.
End December 2004, the fourth control after
10 months of drug therapy.
These are the results on the facial nerve
paresis:
- Pain after her ear missed;
- Modest hyperacusia for noise;
- Wrinkling of the forehead, possible at
both sides, with skin folds less evident to the right one;
- Difficulty to lift the eyebrows: This
movement can be done in both sides, with smaller height reached by the right
eyebrow;
- Reduced palpebral rhyme: It is not more
evident, but there is light appearance when she is under stress;
- Pain to the pressure of the eyebrows
points: It missed in both sides;
- Pain to the pressure of the nasal-genal
points: Some soreness to right one;
- Pain to the pressure of the mandibular
points: It disappeared in both sides;
- The nose-cheek fold: Normal in the left
side; one can see it, but less entrenched in the right side;
- Mouth rhyme falling: just evident to the
left side:
- Ageusia of the anterior third of the
tongue disappeared;
- Disclosure of teeth: It is still
asymmetrical, and reduced to right;
- The smile, a little asymmetrical to right;
- Mouth-eye synkinesias missed;
- Tremors of the orbicularis of the right
eye, rare and no more linked to the inferior right lip: They resurface under
stress;
- Difficulty to puff out one's cheeks:
Normal to lift, still difficult to right; she succeeds even to whistle, if too
with weak strength.
Some times she feels like a mask pressing on
her face mainly to right, where she does fewer labours to lift the cheekbones
when singing, but better in the left side. The vocalisation improved by
loudness and extension. Many persons confirmed her improvement: Her boyfriend
at her side during the current checkup, her family, her friends, and work
colleagues did it.
Therapeutic variation (daily doses, by the
oral via): Chlomipramine stopped, I prescribed: Amitriptyline 10mg +
perphenazine 2mg; Bromazepam 2.5mg; Haloperidol 0.8mg.
Half May 2005, the fifth control.
She had a depressive relapse during the
change of the season that lasted too long. Then, she was depressed, crying,
discouraged, anxious and asthenic. Even now she is afraid of growing fat,
because from the beginning of the drug therapy she has taken (probably, she
recuperated) 3 kilograms. Her singing is well. Currently she has overcome the
critical moment, with substitution of the amitriptyline + perphenazine with
amitriptyline 20mg/daily. Now she is much more serene.
As for the results of the facial paresis,
the right nose-cheek fold is more evident, even if it does not have the depth
of the left homologous. Wrinkling of the right side forehead is in further
recover, but even here it is not still complete. The pain to the pressure of
the exit point of the intermediary claw of the facial nerve, to right, is full
missing. The tremors to the right eye orbicular muscle is more rare, and they
appear mainly only under stress. Also, the lachrymation of the right eye
reduced very much. The falling mouth rhymes reduced more, and it is only
visible if well observed.
Therapeutic variation (daily doses, by the
oral via): Amitriptyline 16mg.
End November 2005, the sixth checkup.
She is in a period of strong irritability
strong [A seasonal phenomenon?], and she has mood alterations. To times she
feels as worn-out. When she is relaxed it is seen even by her face that it is
symmetrical and regulate. When otherwise she is irritable or has slept a few,
her pronunciation becomes more embarrassed and a tremor appears of the muscles
of the right half-face. Then, she has pronunciation difficulty of the
"c" that becomes aspirated, of the "f", of the
"b" and of the "p". In those conditions even frequent
myoclonias in the left half-face occur, When she is singing, she has not any
problem.
With the cool, [A known stress inducer] her
symptoms worsen, and the feeling of a mask on the face reappears (Cocchi, 2005
) a thing that worries her. As for her face, there are not other outcomes of
the facial nerve paresis, which, evidently, was a bilateral paralysis.
According to the patient, the mood change is a following of occurring of the
just described symptoms. However, she sleeps badly, with frequent awakenings
and bad dreams.
Therapeutic variation (daily doses, by the
oral via): Creatine 3 g; pyridoxine 150mg.
Discussion.
No doubts that about the fact that, at the
first visit, I was dealing with, in part, a peripheral bilateral paresis of the
facial nerve (pair VII of cranial nerves), due to Herpes Simplex. This is
considered today an important causal factor of paralysis of the facial nerve,
if not the more important in absolute (Sugita and coll., 1995; Marakami and
coll., 1966; Furuta and coll., 1998).
Two and half years later since the acute
onset, several noticeable symptoms could be observed, too in asymmetrical way,
with right prevalence. I was in front of one of those cases where full recovery
did not happen, and, to the actual state of the common knowledge, it would
never be. In facts, in March 2002, the Neurophysiological Clinics report stated
"stabilized outcomes".
If we would give a graduation level to these
results, by using the staircase of House and Brackman, 1985 (although a little
controversial), we could say so.
We were between the degree II, (Slight
weakness on close inspection, slight synkinesis; Normal tone & Symmetry.
Forehead: Good to moderate movement. Eye: Complete closure with minimum effort.
Mouth: Slight asymmetry) and the degree III (Obvious but not disfiguring
facial asymmetry. Synkinesis is noticeable but not severe. May have hemi-facial
spasm or contracture; Normal tone & Symmetry. Forehead: No movement. Eye:
Incomplete eye closure. Mouth: Asymmetrical with maximum effort).
The concomitant finding either of stress
symptoms that depression drove me to think that perhaps the outcomes of the
herpetic paralysis could have been modified, at least in part, if I could
subtract these two components. Fifteen months after the starting of specific
drug therapies many changes happened. The stress and the depression symptoms
reduced. In the same time, the mobility of the facial muscles, used in singing,
is decidedly improved, and this is not a subjective opinion of the woman.
The unintentional post-paralytic eye-mouth
and vice versa synkinetic activity, appear, if so, as limited to the right
side. The headache beyond the right ear disappeared. The wrinkling of the
forehead is nearly normal, not fatiguing. Even the asymmetry between the two
sides of the face reduced. The soreness to the exit point of the claws of the
facial nerve did not occur. The ageusia missed. The mobility of the inferior
lip is more harmonic and the right mouth fissure is less open.
After about 21 months from the beginning of the drug
therapy, we may reasonably sustain that, at least like here, even
"stabilized", - that means "unmanageable" - outcomes of
peripheral facial nerve paresis, could be faced with good success. It happened
the same for the treatment of outcomes of an "idiopathic" facial
nerve paresis, then interrupted by the patient (Cocchi, 2003).
References.
Cocchi R. Stabilized outcomes of idiopathic
paralysis of the facial nerve (Bell's paralysis) and stress: An attempt of an
antistress drug therapy lasting 10 months. Marzo 2003 <www.stress-cocchi.net/Other4.htm>.
Cocchi R. "Come una
maschera che preme sul volto". Su
un particolare sintomo tra gli esiti stabilizzati di paralisi del nervo
facciale. Febbraio 2005
<www.stress-cocchi.net/index-it.htm/Other17-it.htm>.
Furuta Y, Fukuda S, Chida E, Takasu T,
Ohtani F, Inuyama Y, Nagashima K.. Reactivation of Herpes Simplex virus type 1
in patients with Bell's palsy. J Med Virol 1998; 54:162-166.
House JW, Brackman DE. Facial nerve grading
system. Otolaryngol Head Neck Surg 1985;93:146-147.
Murakami S, Mizobuchi M, Nakashiro Y, et al.
Bell palsy and Herpes Simplex virus: Identification of viral DNA in endoneurial
fluid and muscle. Ann Intern Med 1996;124:27-30.
Sugita T, Murakami S, Yanagihara N, Fujiwara
Y, Hirata Y, Kurata T. Facial nerve paralysis induced by Herpes Simplex
virus in mice: An animal model of acute and transient facial paralysis. Ann
Otol Rhinol Laryngol 1995;104:574-581.
Posted on Internet on June 2004. Copyright by Renato Cocchi, 2004.
Autho's address: dr Renato COCCHI, via Rabbeno, 3
42100 Reggio Emilia
renatococchi@aliceposta.it
Drug modulation of stress reactions
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