Facial paralysis on departure – a puzzling patient

The man has already become inventive: Whenever he is sitting on the plane and can no longer move the right half of his face properly, he tries different tricks. He yawns, covers his nose and swallows, rubbing his cheek with a bottle of warm water. Or he sprays decongestant sprays into his nostrils. With success: just a few minutes after the start, the man can usually smile again, frown and pucker up his lips. The earache that occurred at the same time has also disappeared.

The man, a 57-year-old American from California, endured the constant facial paralysis for four years – also because it usually disappears after a few minutes. He travels a lot and sits on a passenger plane an average of nine times a week. And the same thing always happens: the machine starts, he cannot equalize the pressure on the right and gets an earache. The right half of his face slackens and feels numb, but he never has dizziness, hearing impairment or tinnitus. The facial expressions on the left side of the face also remain.

Some pre-existing conditions, several medications

But at some point the problems with departure became more severe and frequent. Once the complaints also occurred during the landing approach. Once he was unable to control the right half of his face while driving a car after overcoming an altitude of around 1,800 meters. Then the man finally decides to see his family doctor.

The patient has a number of previous illnesses: he is taking medication for his hypothyroidism, is obese with a body mass index of 38 and suffers from sleep apnea, which he can manage with a breathing mask while sleeping. He does not suffer from otitis media more often, they could have explained why he cannot equalize the pressure on the right.

Besides the thyroid medication, vitamin D and a testosterone patch, he does not get any medicines. He only regularly fetches the decongestant nasal drops from the pharmacy and uses them as a preventative measure on flights. He does not smoke and only drinks some alcohol occasionally; there are no neurological diseases in his family history.

When the doctor examines him, he finds no abnormalities. The man can move his facial muscles equally well on both sides. But the cranial nerves are also intact; in addition to the facial nerve, they also include nerves that control the eye muscles, which are responsible for touch sensations on the face and which enable hearing or swallowing. In the hearing test, the patient scores well on both sides, and his eardrum also looks healthy.

What is the cause of the recurring facial paralysis?

Sharp turn in a narrow canal

Because the family doctor can’t figure out the symptoms, he refers his patient to the University of California medical school. As reported by a team of internists, ENT doctors and neuroscientists in the “Journal of Medical Case Reports”, the specialists have magnetic resonance and computed tomography images made of the man’s head.

The facial nerve, also called the facial nerve, follows a special anatomy in almost everyone: After the nerve fibers have emerged from the brain stem, they run through a small opening in the skull into the so-called petrous bone. This houses, among other things, the middle and inner ear. The nerve is embedded here in a narrow canal that curves downwards in a sharp curve. Small nerves branch off on its way from the brain stem through the skull bones, but most of the facial nerve leaves the skull at the temporal bone and supplies the mimic muscles.

While the nerve tissue looks healthy on the man’s magnetic resonance images, the CT images reveal a problem: the narrow facial canal on the right side appears gashed and frayed. Just a tiny change in this structure can cause a changing external pressure to compress the nerve running in the canal. The short-term paralysis, which disappears again after the pressure has been equalized, could be the result.

The conclusion of the medical professionals: The middle ear, in which pressure builds up again and again and which is located near the facial canal, must be relieved. Therefore, ENT doctors cut a small hole in the eardrum that separates the middle ear from the external ear canal and insert a tiny tube into it. This allows the pressure in the middle ear tympanic cavity to equalize that of the surrounding air.

So-called ventilation tubes are part of the routine measures of ENT doctors. Usually, however, the patients are small children, because their anatomical structures are often so narrow that it is difficult to equalize the pressure. As a result, they keep getting middle ear infections – ventilation tubes then relieve strain for some time.

The ventilation tube also helps the frequent flyer: after six months, the man reports that he is flying several times a week again and has no more symptoms. He also no longer needs decongestant nasal drops. The tube can remain in his eardrum, but he must be examined regularly by an ENT doctor.

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