Asymmetric Crying Facies

Figure 4.59. Facial nerve palsy occurred in this infant as a result of application of forceps. It may also occur following prolonged labor in a mother with a prominent sacral promontory. Note the ptosis and drooping mouth on the right side.

Figure 4.60. This shows the same infant crying. The facial palsy becomes readily apparent. This demonstrates how easily the diagnosis may be missed in a quiet or sleeping infant. There is diminished movement of the affected side of the face, the eye frequently but not always remains partly open, the nasolabial fold is absent and the mouth droops, being drawn over to the healthy side when the infant cries. Note that the forehead is smooth on the affected side. Restoration of normal function and disappearance of the paresis may be complete in a few days or usually within a few weeks. Permanent paralysis is exceptional and suggests a central lesion.

Figure 4.59. Facial nerve palsy occurred in this infant as a result of application of forceps. It may also occur following prolonged labor in a mother with a prominent sacral promontory. Note the ptosis and drooping mouth on the right side.

Central Paresis Nervus Facialis

4.60

4.62

Central Paresis Nervus Facialis

Figure 4.61. Facial palsy of the left side in an infant. This infant shows the typical findings in that he is unable to close his eye or contract the lower facial muscles and has loss of the nasolabial fold on the affected side. In traumatic facial paresis frequently only the mandibular branch of the facial nerve is affected. With central facial paresis the two lower branches are affected allowing for movement of the forehead. Facial paresis in Möbius syndrome is usually bilateral and incomplete and the face is expressionless.

Figure 4.62. Congenital hypoplasia of the depressor anguli oris muscle (angular depressor muscle). The localized facial weakness in which the lower lip on one side fails to be depressed on crying results in an "asymmetric crying facies." The resulting facial asymmetry when the child cries may be misinterpreted. There is a weakness of the muscles controlling movement of die mouth but not diose of the upper face. The nasolabial folds are normal and the affected side will not move when the infant cries. The normal side of the face is assumed to be abnormal because the lower lip on the intact side appears to be pulled down and everted. This is a benign condition and is not facial palsy. It lessens as the child gets older. It may be associated with odier anomalies, particularly those of the cardiovascular system.

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Asymmetrical Crying Face Brachial Plexus Palsy

Figure 4.63. Erb's palsy (upper brachial plexus injury) occurs as a result of traction on the brachial plexus (most often the upper nerve roots, C3, C4, and C5). This type of injury occurs most commonly in cases of shoulder dystocia. It presents with the infant lying with the affected upper extremity adducted and internally rotated, the elbow extended, and the hand partially closed with the palm directed outwards and posteriorly resulting in the typical "waiter's tip" position. The majority of these injuries resolve spontaneously in 3 to 4 weeks.

Figure 4.64. Bilateral involvement of the upper brachial plexus resulting in the typical position in both upper extremities. In the rare event of a bilateral palsy the possibility of damage to the spinal cord has to be considered. Note that infants with Erb's palsy may lack a Moro response on the affected side.

Asymmetric Diaphragm

Figure 4.65. Anteroposterior and lateral radiograph of the chest in an infant widi a right Erb's palsy. Note die ipsilateral paralysis of the right diaphragm due to phrenic nerve palsy which may occur in association widi upper motor brachial plexus trauma. A rare complication associated widi Erb's palsy is a Horner's syndrome on the same side, due to involvement of die cervical sympathetic nerves. If Horner's syndrome persists, the infant may develop heterochromia iridis caused by failure of development of secondary pigmentation in the affected eye.

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