Asymmetry of the face is more common in nervous diseases and dental pathologies. Less commonly, the cause of the symptom is trauma, ophthalmological, otolaryngological, congenital diseases. Violation can be static or dynamic, develop due to disorders of innervation, edema, excess or lack of tissue. Determining the cause of asymmetry is carried out using data from general, dental, neurological, otolaryngological examination, radiography, and other imaging techniques. Treatment prior to diagnosis is not indicated.
Why Facial Asymmetry Occurs
Physiological states
Slight static (visible at rest) asymmetry of the face is a physiological norm and occurs in almost all people. A difference in proportions within 3-5 degrees or 2-3 mm is considered normal.
Sometimes visually noticeable differences between the halves of the face are exacerbated by the features of facial expressions. Such asymmetry (noticeable during the tension of the facial muscles) is called dynamic. Differences tend to get worse with age, as a person repeatedly strains the same muscles asymmetrically. This affects the condition of soft tissues, especially the formation of wrinkles.
Damage to cerebral structures and meninges
Asymmetry of the face is provoked by traumatic injuries and diseases of the central nervous system of various origins. The list of pathologies includes:
- Brain compression. Acutely develops due to severe head injury, and cerebral edema. Gradually progresses with hydrocephalus, tumors, and cystic formations located in the cranial cavity.
- Stroke. Occurs acutely against the background of arterial hypertension, atherosclerosis, and angina pectoris. Maybe ischemic or hemorrhagic. The outcome of both variants of the pathology is a focal brain lesion, causing disturbances in the nervous regulation and asymmetry of the face.
- Encephalitis. Focal disorders are the result of not only circulatory disorders but also inflammatory processes in the brain. Facial asymmetry is sometimes observed in patients who have had primary (tick-borne, Japanese mosquito) or secondary (influenza, measles, post-vaccination) forms of encephalitis.
- Meningitis. The reason for the symmetry disorder can be the involvement of the cranial nerves, the spread of infection to the brain structures with the development of meningoencephalitis. The symptom is more often detected with purulent meningitis, and basilar tuberculous meningitis.
- Neuroleukemia. Formed as a complication of leukemia. Asymmetry of the face may be due to dysfunction of the cranial nerves, the occurrence of leukemic meningoencephalitis, and compression of brain structures in patients with pseudotumors form of the disease.
- Progressive hemiatrophy of the face. The gradual reduction of half of the face is due to atrophy of bones and soft tissues, presumably caused by exposure to the autonomic centers. Changes appear in a limited area, over time, spread to the entire half of the face.
- Oromandibular dystonia. It is manifested by violent movements: squeezing, lateral movements of the jaws, opening and closing the mouth, which is accompanied by a curvature of the lips, a violation of symmetry at the level of the cheeks. The occurrence of pathology is provoked by the defeat of the basal ganglia.
Facial asymmetry
Pathologies of the cranial nerves
The most common disease of the cranial nerves that cause asymmetry is neuritis of the facial nerve. The reason for the violation of symmetry is paresis or paralysis of facial muscles. A typical clinical picture includes flattening of the nasolabial fold, drooping of the corner of the mouth, inability to close the eyelid, and skewing of the face to the healthy side. A type of facial paralysis is Ramsey-Hunt syndrome. Along with weakness of facial muscles, patients experience ear pain, dizziness, and hearing loss.
In patients with Bogorad's syndrome, branches of the facial or abducens nerve grow into the salivary and lacrimal glands. The disease develops at an early age, rarely becomes the result of injuries in adults, and is accompanied by lacrimation, and increased salivation from the side of the lesion. The defeat of the facial nerve is manifested by paresis of the facial muscles, the abducens nerve - hearing impairment, and deformation of the auricle. In children, facial asymmetry progresses as they grow.
Jaw lesions
A fairly common dental cause of facial asymmetry is diseased, the consequences of injuries, congenital anomalies of the jaws, and TMJ:
- Arthrosis of the TMJ. The symptom appears in the process of opening the mouth, due to the displacement of the lower jaw to the affected side. The disease develops gradually, accompanied by crunching, clicking, morning stiffness, and dull pains.
- Ankylosis of the TMJ. The asymmetry of the face remains at rest, aggravated by an attempt to open the mouth. The midline of the face is shifted to the affected side. The lower jaw is retracted downward by no more than 1 cm, horizontal movements are impossible.
- Contracture of the lower jaw. There are restrictions when opening the mouth, a decrease in the amplitude of movements of the lower jaw. The midline also shifts towards the lesion. Pathology can be unstable (inflammatory) or resistant (cicatricial).
- Ameloblastoma. An odontogenic benign tumor that destroys the tissues of the jaw can reach a significant size and cause significant facial deformity. The neoplasm grows slowly, and asymmetry in the jaw area becomes the first symptom of the disease.
- Other benign tumors of the jaws. The symptom is often found in osteomas, osteoid osteomas, osteoblastoclastomas.
- Cancer of the upper jaw. Deformation occurs with sufficiently large size of neoplasia, due to the growth of the tumor itself, the destruction of nearby anatomical structures, and inflammatory edema.
- Cancer of the lower jaw. Asymmetry of the face is noted in the case of germination of the neoplasm in the nearby soft tissues, and deformation of the alveolar process.
Another reason for asymmetry is jaw defects, which can be congenital or acquired: resulting from trauma, osteomyelitis, tuberculosis, syphilis, and operations for oncological diseases. With a defect in the upper jaw, the symptom appears due to the retraction of the cheek, which may be accompanied by the formation of oronasal and oroantral anastomoses.
A defect in the lower jaw is characterized by a violation of the oval of the face. Due to the displacement of the jaw towards the midline, the asymmetry is aggravated during the opening of the mouth. A violation of symmetry is also often manifested by micrognathia - a decrease in the jaw due to underdevelopment or previous damage. With upper micrognathia, the lower teeth overlap the upper ones (reverse overlap), with the lower variant of the pathology, a sloping chin is observed.
Diseases of the salivary glands
Inflammatory processes and volumetric formations of the salivary gland cause deformation of the lower outer part of the face, causing asymmetry.
- Purulent parotitis. In the projection of the parotid salivary gland, a rapidly increasing painful swelling appears. An increase in temperature and symptoms of intoxication are detected.
- Mucocele. Causes asymmetry of the face as a result of damage to the salivary glands located in the ear and submandibular regions. The swelling is painless, the condition is satisfactory, and there are no signs of inflammation.
- Cyst. As in the previous case, the symptom is observed when the parotid, submandibular gland is involved, and pain and inflammatory manifestations are not observed. Against the background of infection, subfebrile condition and local pain are possible.
- Adenoma. Benign tumor with slow growth. With an increase in size, along with asymmetry, unpleasant sensations and a decrease in salivation are noted.
- Tumors. In the area of the salivary glands, benign lipomas, neurinomas, and angiomas are formed. According to clinical manifestations, neoplasms resemble adenoma. The list of malignant neoplasias includes sarcomas and carcinomas, which are characterized by rapid growth and destruction of soft tissues. Pathologies are often accompanied by paresis of the facial nerve.
Other dental diseases
Other inflammatory dental conditions that can cause facial asymmetry include:
- Periostitis of the jaw (flux). Only the periosteum suffers, and the jaw itself remains intact. Flux is more often caused by dental diseases. The cause of asymmetry is local edema, the formation of an abscess under the periosteum.
- Periapical abscess. An abscess is formed in the tissues around the root of the tooth, provoked by acute periodontitis. It is manifested by a severe throbbing pain in the area of the affected tooth. Deformation of the face is due to the spread of edema to the surrounding soft tissues.
- Periorbital abscess. It develops with lesions of the teeth, and inflammatory processes in the surrounding tissues. It is accompanied by a violation of the general condition, toothache, and dense edema, in the center of which a site of fluctuation is subsequently formed.
Non-inflammatory causes of asymmetry include crossbite, a condition in which the dentition crosses during the closure of the jaws. May be congenital or acquired. It is characterized by a shift of the chin to the side, a receding lip on one side, and a flattening of the lower parts of the face on the other.
Facial trauma
Temporary asymmetry of the face, due to soft-tissue edema, is observed with soft tissue bruises, and facial hematomas. Occurs after a blow or fall, increases rapidly within a few hours, and gradually disappears over 1-2 weeks. At the recovery stage, “fading” is noted - a consistent change in skin color in areas of hemorrhage. In fractures, asymmetry is caused not only by edema but also by the displacement of the hard structures of the facial skull. Symptoms are caused by:
- Fracture of the lower jaw. The violation of symmetry is more noticeable along the outer or lower edge of the cheek. In the oral cavity, a step is found (discontinuity of the dentition) in the area of the fracture.
- Fracture of the upper jaw. The face becomes asymmetrical due to swelling in the upper part of the cheek. Hemorrhages in the periorbital zone, and neurological disorders are possible.
- Fracture of the zygomatic bone. Initially, the swelling is localized in the cheekbone area, subsequently, it quickly spreads up and down along the outer surface of the face. There may be periorbital hemorrhage, or double vision.
ENT diseases
Silent sinus syndrome occurs as a result of atelectasis of the maxillary sinus. It is manifested by a decrease in the volume of the paranasal sinus, unilateral deformation of the face: lowering of the lower edge of the orbit, displacement of the eyeball into the orbit, and retraction of the cheek. Pathology develops over many years, gradually progresses, and in the final stages is accompanied by ophthalmic disorders.
In patients with cysts of the paranasal sinuses, unlike in the previous case, asymmetry develops due to an excess, and not due to a lack of tissue. The symptom is determined only with large cysts, manifested by unilateral deformation of the forehead or cheek. Pain in the sinus area, dull headaches, and recurrent sinusitis are observed.
Congenital and childhood pathologies
Facial asymmetry is diagnosed in the following congenital diseases and pathologies of childhood:
- Sturge-Weber Syndrome. A congenital disease in which angiomas form on the skin and meninges. With hydrocephalus, and hemiparesis, asymmetry of the face develops on the side opposite to the location of the angiomas.
- Torticollis. The congenital form is due to the underdevelopment of the sternocleidomastoid or trapezius muscle, the acquired form is due to various diseases and injuries. The ear, eyebrow, and eye of the child on the affected side are lower than on the healthy side. The palpebral fissure is somewhat narrowed.
- Termite-Duclos disease. A genetically determined pathology, the main manifestation of which is a neoplasm of the cerebellum. Even before the onset of tumor growth, the disease can be suspected by the asymmetry of the facial skeleton, gingival hyperplasia, congenital anomalies of the hands, and some other signs.
- Acute intermittent porphyria. Hereditary disease, is manifested by seizures caused by disorders of porphyrin metabolism. Facial asymmetry is observed in severe cases, occurs about a week after the onset of symptoms from the gastrointestinal tract, and is combined with other neurological disorders.
- Hare's lip. An anomaly of development in which one or two clefts of the upper lip are detected, located on the sides of the midline. With a concomitant cleft palate, the deformation is aggravated by a "failure" in the middle part of the face, a violation of the shape of the nose.
- Stigmas of embryogenesis. Symmetry violation can be determined in several small anomalies: a change in the shape of the skull, deformities of the nose, eyes, and dentoalveolar system.
Other reasons
Other possible causes of facial asymmetry include:
- Hydrogen peroxide poisoning. The symptom is detected in violation of cerebral circulation, supplemented by impaired speech, hearing, and coordination of movements.
- Actinomycosis. Asymmetry is observed in maxillofacial actinomycosis, caused by the formation of an infiltrate in the area of masticatory muscles, and the development of trismus.
- Kallman syndrome. With this form of hypogonadism, the symptom is caused by malformations and small anomalies of the face, combined with eunuchoidism, cardiovascular disorders, and gynecomastia.
- Botulism. Accompanied by the facial asymmetry in neurological disorders that cause paresis or paralysis of facial muscles.
Diagnostics
Establishing the cause of facial asymmetry is most often carried out by dentists or neurologists. If appropriate symptoms are detected, the patient is referred to otolaryngologists, oncologists, endocrinologists, and other specialists. The examination plan may include the following diagnostic procedures:
- Questioning, physical examination. The doctor establishes the time and circumstances of the onset of the symptom, and asks the patient about other manifestations of the disease. Assesses the severity of asymmetry at rest, with facial and chewing movements. Reveals other changes: swelling, redness, blanching, increased local temperature, and tumor-like formations.
- Dental checkup. Includes the study of the condition of the teeth, gums, hard and soft palate, mucous membranes of other areas, and bones of the facial skeleton. Allows you to confirm the presence of diseased teeth, inflammation, trauma, suppuration, and tumors.
- Neurological examination. The specialist studies the innervation of the facial muscles, inviting the patient to perform certain movements: wrinkle the forehead, raise and lower the eyebrows, puff out the cheeks, show the tongue, bare the teeth, follow the movements of the neurological hammer with the eyes. The neurologist then palpates the available nerve exit points.
- Otorhinolaryngological examination. Provides special research. If a pathology of the paranasal sinuses is suspected, echosinusoscopy or diagnostic puncture can be performed. With complaints of hearing impairment, audiometry, tuning fork, etc. are performed. In vestibular disorders, vestibulopathy and rotational tests are recommended.
- Radiography. Taking into account the identified pathological changes, the patient is prescribed an x-ray of the tooth and an x-ray examination of the jaw or paranasal sinuses. In some cases, x-rays of the skull, and cervical spine are needed.
- Ultrasound. During the examination, sonography of the salivary glands, paranasal sinuses, and soft tissues can be performed. If signs of cerebral compression are detected, echoencephalography is indicated.
- Other Imaging Techniques. Most often, CT or MRI is used to clarify the diagnosis, a detailed study of the nature of the changes, and the volume, and location of the pathological focus. In the case of neurological pathology, PET-CT, and SPECT of the brain can be prescribed.
- Laboratory tests. According to the general blood test, the presence and severity of inflammation are judged, and the pathogen and its sensitivity to antibiotics are determined based on the results of a microbiological study. With volumetric formations, a histological and cytological examination of smears, punctures, and biopsy specimens is carried out.
Elimination of facial asymmetry
Treatment
The etiology of facial asymmetry is very diverse. Many diseases accompanied by this symptom can pose a serious threat to the health of the patient, especially if treatment is started late. Self-medication in such cases is unacceptable, the appearance of this symptom should be considered as a reason for immediate medical attention.
Conservative therapy
The treatment plan varies depending on the characteristics of the pathology. In many cases, a special diet is recommended. In case of dental diseases, caries, pulpitis, and periodontitis can be treated. Patients with facial asymmetry are prescribed medications for the following groups:
- Analgesics. Indicated for severe pain syndrome. Intramuscular injections or taking tablet forms are possible.
- NSAIDs. Required to reduce the severity of inflammation, swelling, and pain. Means of general action are taken in short courses to reduce the risk of side effects from the liver and gastrointestinal tract.
- Antibiotics. Necessary for general bacterial infections, and local inflammatory processes. First, broad-spectrum drugs are used, after receiving the result of microbiological analysis, the antibiotic therapy regimen is adjusted taking into account the sensitivity of the pathogen.
- Antiseptics. Topical medications are used in the form of rinses. Recommended in the presence of inflammation, and wounds on the mucous membrane, after surgery.
In some cases, drug therapy is supplemented with physiotherapy. In the treatment of diseases that provoke facial asymmetry, electrical stimulation, UHF, drug electrophoresis, and other methods can be prescribed. In oncological pathologies, chemotherapy and radiation therapy are carried out.
Surgery
Depending on the nature of the disease, the following operations are carried out:
- Nervous: endoscopic or transcranial evacuation of hematomas, removal of crushed areas of the brain in case of head injury, excision of tumors and abscesses, bypass interventions, static suspension of the corner of the mouth, dynamic suspension of the corner of the eye or mouth.
- Dental: tooth extraction, excision of a cyst or tumor of the salivary gland, the opening of oral abscesses.
- Maxillofacial: arthrocentesis, therapeutic arthroscopy, lavage, TMJ endoprosthesis, the opening of abscesses and soft tissue phlegmons, rhinocheiloplasty, rhinocheilognatoplasty, and other methods of correcting facial clefts.
- In case of injuries: osteosynthesis of the jaw, conventional and intermaxillary ligature tying, splinting of the jaw.
- Otolaryngological: removal of cysts of the paranasal sinus.