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Facial Nerve Paralysis

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Title: Facial Nerve Paralysis


1
Facial Nerve Paralysis
  • ?.?. ?????????? ????????????????

2
Outlines
  • Anatomy
  • Classification
  • Evaluation
  • Electrodiagnosis testing
  • Management
  • Bells palsy ,Ramse Hunt syndrome
  • Temporal bone fracture

3
Anatomy of Facial nerve
  • The facial nerve contains approximately 10,000
    fibers
  • 7000 myelinated fibers innervate the muscles of
    facial expression, stapedius muscle,
    postauricular muscles, posterior belly of
    digastric muscle, and platysma
  • 3000 fibers form the nervus intermedius (Nerve of
    Wrisberg)
  • sensory fibers (taste) from the anterior 2/3 of
    the tongue
  • taste fibers from soft palate via palatine and
    greater petrosal nerve
  • parasympathetic secretomotor fibers to the
    parotid, submandibular, sublingual, and lacrimal
    gland

4
Anatomy of Facial nerve
  • 1) Intracranial part
  • Supranuclear segment
  • Nuclear segment
  • Infranuclear segment
  • Cerebellopontine angle
  • Internal acoustic canal
  • Labyrinthine segment
  • Tympanic segment
  • Mastoid segment
  • 2) Extracranial part

5
Supranuclear segment
  • Cerebral cortex ? Corticobulbar tract ? Facial
    nucleus (pons)
  • Upper face ? crossed uncrossed
  • Lower face ? crossed only

6
Nuclear segment
  • Facial motor nucleus
  • lower 1/3 of Pons
  • abducent nucleus
  • Out from brain stem at pons recess between olive
    and inferior cerebellar peduncle

7
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8
Nervous intermedius
  • Parasympathetic secretory fibers arise from
    superior salivatory nucleus
  • These preganglionic fibers travel to the
    submandibular ganglion via the chorda tympani
    nerve to innervate the submandibular and
    sublingual glands
  • And to sphenopalatine ganglion via greater
    superficial petrosal nerve to innervate lacrimal,
    nasal, and palatine gland

9
Nervous intermedius
  • Secretory fibers of lesser superficial petrosal
    nerve tranverse tympanic plexus, synapse in otic
    ganglion, and travel via auriculotemporal nerve
    to innervate parotid gland
  • Taste fibers from anterior 2/3 of tongue reach
    geniculate ganglion via chorda tympani nerve and
    from there travel to the nucleus of the tractus
    solitarius

10
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11
Infranuclear segment
  • Cerebellopontine angle
  • Internal acoustic canal
  • Labyrinthine segment
  • Tympanic segment
  • Mastoid segment

12
Cerebellopontine angle
  • The facial nerve and nervus intermedius exit the
    brain stem at the pontomedullary junction and
    travel with CN VIII to enter the internal
    acoustic meatus

13
Internal acoustic canal
  • Motor facial nerve (medial)
  • Nervus intermedius (between)
  • Acoustic nerve (lateral)

14
Labyrinthine segment
  • Fallopian canal
  • Shortest Narrowest part
  • Temporal bone
  • Facial nerve enter fallopian canal until middle
    ear
  • First genu
  • Geniculate ganglion
  • Branches
  • Greater superficial petrosal nerve ? lacrimal
    gland
  • Lessor superficial petrosal nerve ? parotid gland

15
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16
Tympanic segment
  • First genu ? above oval window ? stapes
  • Second genu beyond middle ear
  • Out of cranium through stylomastoid foramen

17
Mastoid segment
  • Stylomastoid foramen
  • Branches
  • Motor nerve to stapedius muscle
  • Chorda tympani nerve between malleus and incus
  • secretomotor Submandibular Sublingual gland
  • taste fiber anterior 2/3 of tongue

18
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19
Extracranial segment
  • Posterior auricular nerve auricularis,
    occipitalis and sensation at auricular, post
    auricular area
  • Branch to posterior belly of digastric muscle and
    stylohyoid muscle
  • Temporal branch muscle above zygoma
  • Zygomatic branch orbicularis occli
  • Buccal branch buccinator and upper lip
  • Marginal mandibular branch orbicularis oris and
    lower lip
  • Cervical branch platysma

20
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21
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22
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23
Physiology
  • Efferent fibers from the motor nucleus
    innervate muscles of facial expression,
    post-auricular, stylohyoid, posterior digastric,
    and stapedius muscles
  • Efferent fibers ANS (preganglionic
    parasympathetic fiber)
  • sphenopalatine ganglion to lacrimal glands and
    mucinous glands of nose
  • submandibular ganglion to submandibular and
    sublingual glands

24
Physiology
  • Afferent fibers convey taste from anterior
    two-thirds of tongue to nucleus tractus
    solitarius via lingual nerve, chorda tympani, and
    nervus intermedius.
  • Afferent fibers mediate sensation from posterior
    external auditory canal, concha, ear lobe, and
    deep parts of face

25
Classifications of facial nerve injury
  • Seddon classification of nerve injury
  • Neuropraxia
  • Axonotmesis
  • Neurotmesis

26
Classifications
  • Sunderland classification of nerve injury
  • 1 damage Compression
  • 2 damage Interruption of axoplasm
  • 3 damage Disruption of myelin
  • 4 damage Disruption of perineurium,
    myelin and axon
  • 5 damage Transection of nerve

27
Sunderland Classification of nerve injury
28
Nerve injury
  • neurapraxia Sunderland grade 1
  • axonotmesis Sunderland grade 2-3
  • neurotmesis Sunderland grade 4-5

29
Degeneration
  • Interruption of the continuity of the axon
    separates the distal axon from its metabolic
    source, the neuron or cell body
  • Wallerian degeneration of the distal axon and
    myelin sheath begins within 24 hours
  • Macrophages phagocytose degraded myelin and axons

30
Regeneration
  • Complete
  • Partial
  • Simple misdirection
  • Clinical expression synkinesis or associated
    movement
  • Complex misdirection
  • Clinical expression mass movement

31
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32
Differential Diagnosis
  1. Extracranial
  2. Intratemporal
  3. Intracranial

33
Extracranial
  • 1. Traumatic
  • Facial lacerations
  • Blunt forces
  • Penetrating wounds
  • Mandible fractures
  • Iatrogenic injuries
  • Newborn paralysis

34
Extracranial
  • 2. Neoplasm
  • Parotid tumors
  • Tumors of the external and middle ear
  • Facial nerve neurinomas
  • Metastatic lesions
  • 3. Congenital absence of facial musculature

35
Intratemporal
  • 1. Traumatic
  • Fractures of petrous pyramid
  • Penetrating injuries
  • Iatrogenic injuries
  • 2. Neoplastic
  • Cholesteatoma
  • Facial neurinomas
  • Hemangiomas
  • Meningiomas
  • Acoustic neurinomas

36
Intratemporal
  • 3. Infectious
  • Herpes zoster oticus
  • Acute otitis media
  • Chronic otitis media
  • Malignant otitis externa
  • 4. Idiopathic
  • Bell's palsy
  • Melkersson-Rosenthal syndrome
  • 5. Congenital osteopetroses

37
Intracranial
  • 1. Iatrogenic injury
  • 2. Neoplastic
  • 3. Congenital
  • Mobius syndrome
  • Absence of motor units

38
History
  • Onset
  • Previous symptoms
  • Complete or incomplete
  • Unilateral or bilateral
  • Pain
  • Underlying disease (vestibulocochlear)
  • Associate symptoms
  • Alteration in taste or lacrimation

39
History
  • Family history
  • Trauma
  • Hx of viral infection
  • Vaccination
  • DM
  • HTN
  • Pregnancy

40
Physical examination
  • ENT exam
  • Nervous system
  • Location
  • Severity

41
Evaluation of Facial paralysis
  • Clinical feature
  • Central VS Peripheral facial paralysis
  • Complete head and neck examination
  • Cranial nerve evaluation
  • Electrodiagnostic testing
  • Topographic diagnosis

42
Central facial paralysis
  • Upper motor neurone lesion
  • Movements of the frontal and upper orbicularis
    oculi tend to be spared
  • Because of uncrossed contributions from
    ipsilateral supranuclear areas
  • Involvement of tongue
  • Involvement of lacrimation and salivation

43
Peripheral paralysis
  • Lower motor neurone lesion
  • At rest
  • less prominent wrinkles on forehead of affected
    side, eyebrow drop, flattened nasolabial fold,
    corner of mouth turned down
  • Unable to
  • wrinkle forehead, raise eyebrow, wrinkle
    nasolabial fold, purse lips, show teeth, or
    completely close eye

44
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45
House-Brackmann grading system
  • Grade I - Normal
  • Grade II - Mild dysfunction, slight weakness on
    close inspection, normal symmetry at rest
  • Grade III - Moderate dysfunction, obvious but not
    disfiguring difference between sides, eye can be
    completely closed with effort
  • Grade IV - Moderately severe, normal tone at
    rest, obvious weakness or asymmetry with
    movement, incomplete closure of eye
  • Grade V - Severe dysfunction, only barely
    perceptible motion, asymmetry at rest
  • Grade VI - No movement

46
Topographic Diagnosis
  • To determine the anatomical level of a peripheral
    lesion
  • Lacrimation ? Geniculate ganglion
  • Stapedius reflex ? motor nerve of stapedius
    muscle
  • Taste ? chorda tympani

47
Schirmer's Test
  • Geniculate ganglion petrosal nerve function
    test
  • Schirmers test ve when
  • Affected side shows less than half the amount of
    lacrimation seen on the normal side
  • Sum of the lengths of wetted filter paper for
    both eyes less than 25 mm
  • Lesion at or proximal to the geniculate ganglion

48
Stapedius reflex
  • Nerve to stapedius muscle test
  • Impedance audiometry can record the presence or
    absence of stapedius muscle contraction to sound
    stimuli 70 to 100 dB above hearing threshold
  • An absence reflex or a reflex less than half the
    amplitude is due to a lesion proximal to
    stapedius nerve

49
Taste (Electrogustometry)
  • Chorda tympani nerve test
  • Solution of salt, sugar, citrate, quinine or
    Electrical stimulation
  • Compares amount of current require for a response
    each side of tongue
  • Normal difference lt 20 uAmp (thresholds
    differening by more than 25 abnormal)
  • Total lack of Chorda tympani No response at 300
    uAmp
  • Disadvantage False ve in acute phase of Bells
    palsy

50
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51
Minimal stimulation test
  • ???????????????????????????? ? ?????
    ???????????????? ????????????????????????????????
    ????????
  • ????????????????????????????
  • neurapraxia ??????????????????????????????????????
    ????????????
  • axonotmesis ??????????????????????????????????????
    ??????????????????????????????????????????????????
    ??
  • neurotmesis ????????????????????????????????

52
Minimal stimulation test
  • ????????????????????????????????????
  • ???????? ? ???????????????????????????????????????
    ??????????????????????????????????????
  • ???????????????????
  • ?????????????????????????????????????????????????
  • ???????????????????? 3.5 mA ? Wallerian
    degeneration

53
Maximal stimulation test (MST)
  • ??????????????????????????????????? neurapraxia
    ??????? axon ?????????????????????????????????????
    ??????????????????????
  • ??????????????????????????? axonotmesis ???????
    axon ?????????????????????????????????????????????
    ?????????????????????????????????
  • ???????????????????? neurotmesis
    ??????????????????????????????????????????????????
    ????????????????????

54
Maximal stimulation test (MST)
  • ????????????????? 5 mA ?????????????????????????
    ???????
  • ??????????????? ????????? ???? 2
    ??????????????????
  • ?????????????????? facial nerve
    ????????????????????????????? ?????? 12
  • ????????????????? ????????????????????????????
    ?????? 73
  • ?????????????????? facial nerve
    ????????????????????? ?? misdirection ????

55
Electroneurography (ENOG )
  • ???????????????????? MST
  • ????????????????????? ??????????????????
    summating potential
  • ??????????????????????????? amplitude
    ????????????????????????????????????
  • ??? amplitude ??? SP ????????????????????????????
    ???????????? 5-10 ??????????????????????????
    90-95 ?????????????????? facial nerve
    ?????????????????? ????? misdirection???

56
Electromyography (EMG)
  • ??????????????????????????????????????????????????
    ??
  • ???????????????????? facial palsy ?????????????
    10 ???
  • ???????????????? Wallerian degeneration
    ??????????????????????????????????????????????????
    ????????????????????????
  • ????????? fibrillatioin ??????? facial nerve
    ?????????????????????
  • ????????? motor unit potential
    ??????????????????????????????????????????????????
    ???????????

57
Limitation of Electrodiagnostic testing
  1. ??????????????????????????????????????????????????
    ??? 72 ???????
  2. ??????? EMG ?????????????????????????????????????
    ??? 10 ???
  3. ??????????????????????????????
    ?????????????????????????????? (?????? EMG)

58
Management
  • Extracranial etiology
  • Trauma
  • Iatrogenic
  • Neoplasm
  • Intratemporal etiology
  • Fracture
  • Iatrogenic
  • Neoplasm
  • Idiopathic (Bells palsy)
  • Infection

59
Idiopathic facial palsy (Bell's Palsy)
  • Most common cause of facial paralysis (gt50 of
    case)
  • Most age 25-30 yrs.
  • Male Female 1 1
  • Left side Right side 1 1
  • Unilateral gt bilateral
  • Increase risk in
  • pregnancy 3.3 times
  • DM 4.5 times
  • Recurrent rate 10
  • 60 have previous URI

60
Etiology
  • Unknown
  • Microcirculatory failure of vasa nervorum
  • Viral infection (HSV)
  • Ischemic neuropathy
  • Autoimmune reaction
  • Entrapment theory

61
Diagnosis
  • By exclusion
  • Criteria
  • Paralysis or paresis of all muscle groups of one
    side of the face
  • Sudden onset
  • Absence of signs of CNS disease
  • Absence of signs of ear or CPA disease

62
Medical treatment
  • Corticosteroids
  • prednisolone 1 mg/kg/day 7-10 days
  • Corticosteroids combine with antiviral drug is
    better
  • Acyclovir 400 mg 5 times/day
  • Famciclovir and valacyclovir 500 mg bid

63
Surgical treatment
  • Facial nerve decompression
  • Indication
  • Completely paralysis
  • ENOG less than 10 in 2 weeks
  • Appropriate time for surgery is 2-3 weeks after
    paralysis

64
Herpes Zoster Oticus (Ramsay Hunt Syndrome)
  • 3rd most common of peripheral facial paralysis
    (10)
  • Aged gt 60 yrs. or low immune (low CMIR)
  • Virus travels to the dorsal root extramedullary
    cranial nerve ganglion
  • Infected of HZV at auricular, external canal or
    face
  • Prodromal symptoms very similar to those seen in
    Bell's palsy
  • but usually more severe

65
Herpes Zoster Oticus (Ramsay Hunt Syndrome)
  • Symptoms include severe otalgia, facial
    paralysis, facial numbness, and a vesicular
    eruption on the concha, external auditory canal,
    and palate
  • Facial paralysis hearing loss vertigo ?
    canal paralysis
  • Pathophysiology treatment liked in Bell s
    palsy

66
Temporal bone fractures
  • Longitudinal fracture
  • Transverse fracture
  • Mixed fracture

67
Temporal bone fractures
  • Signs
  • bleeding from the external canal
  • hemotympanum
  • step-deformity of the osseous canal
  • conductive hearing loss (longitudinal fracture)
  • sensorineural hearing loss (transverse fracture)
  • CSF otorrhea
  • facial nerve involvement (20 of longitudinal
    fractures and 50 of transverse fractures)

68
Longitudinal VS Transverse
Type of injury Longitudinal Transverse
Incidence 70-90 10-20
Site of injury Temporal , Parietal area Occipital , Frontal area
69
Origin of fracture site Temporal squama Foramen magnum
Direction of injury Posterosuperior of EAC cross roof of middle ear along carotid canal anterior to labyrinthine capsule Between various foramen Jugular F. Hypoglosal F. Labyrinthine capsule
70
Insertion middle cranial fossa middle cranial fossa
Tympanic mb. Middle ear Inner ear ??????????? ?????????????????? ???????????????? ????, hemotympanum ????????? ??????????????????
Hearing loss Vertigo CHL No SNHL Common
71
Facial paralysis Onset 20-25 Delayed, transient 50 Immediate, permanent
Site of lesion Tympanic segment , Perigeniculate ganglion Labyrinthine segment
CSF otorrhea No Common
72
Cardinal SS 1.Bleeding from ear 2.CHL 3.Battles sign 1.VertigoNystagmus 2.SNHL 3.Facial paralysis 4.Hemotympanum
CT-scan Axial sagital section Coronal 20degree coronal oblique section
73
Prognosis
  • Immediate onset paralysis poor prognosis
  • Delayed onset paralysis good prognosis
  • All case of paralysis ? electrical testing

74
Treatment
  • Surgery is treatment of choice
  • Indications for facial nerve exploration
  • incomplete paralysis
  • iatrogenic paralysis
  • Contraindications any case have no poor
    prognostic factors

75
Complications
  • Complications of facial nerve decompression
  • dural tears
  • conductive or sensorineural hearing loss
  • vestibular function loss
  • persistent CSF leaks
  • meningitis
  • injury to the anterior inferior cerebellar artery
    (AICA) or its branches
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