Associated Neurological Findings

Cerebral. The presence of apraxia, hemispacial neglect, aphasia, or Gerstmann's syndrome in association with facial numbness is very helpful in identifying parietal lobe dysfunction in affected patients. Other important manifestations of parietal lobe dysfunction include a homonymous hemianopia (especially within the inferior quadrant); a cortical sensory syndrome in which astereognosis, diminished two-point discrimination, and agraphesthesia are features; and abolition of optokinetic nystagmus toward the side of the lesion.

Cranial Nerves. Ophthalmoparesis involving cranial nerves III, IV, or VI with trigeminal symptoms suggests cavernous sinus or superior orbital fissure pathology. If cranial nerves VI, VII, and/or VIII are involved (ophthalmoparesis, nystagmus, hearing changes), a petrous apex process such as Gradenigo's syndrome (see later) or lesion such as tumor within the lateral pons or cerebellopontine angle should be suspected. Similarly, detection of Horner's syndrome may indicate lateral brain stem or upper cervical spinal cord pathology.

Motor/Reflexes/Cerebellar/Gait. Hemiparesis can result from lesions within the postcentral gyrus and can overlap with sensory loss. Cerebellar abnormalities such as gait ataxia or nystagmus in association with facial numbness may point to a process within the cerebellopontine angle. Detection of Horner's syndrome alone or in combination with dysphasia and ataxia is consistent with a lesion in the lateral medullary region.

Sensory. Although the distribution of sensation on the lower face is via V3, the angle of the jaw is innervated by the C2 to C3 spinal nerves. Numbness or paresthesias in this region may reflect an intramedullary cervical cord process, but a psychogenic etiology should also be considered. "Crossed sensory" syndrome, wherein facial hypesthesia is central to body hypesthesia, indicates a brain stem lesion. Face and body hypesthesia on one side suggest a cortical, subcortical, or midbrain lesion.

Neurovascular. The detection of a bruit over the orbit is suggestive of a carotid-cavernous sinus fistula, especially in the setting of recent head trauma, and may be helpful in discerning trigeminal dysfunction from a cavernous sinus process. Other signs suggestive of carotid or systemic vascular disease increase the suspicion of stroke syndromes.

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