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Facial Nerve
ParalysisDr. Vishal Sharma
Gabriel Fallopius (1523-62)
Anatomy of Facial Nerve Motor root: 7000 axons
Sensory root (Nervus intermedius / Wrisberg):
3000 axons. Joins motor root at fundus of I.A.C.
Motor: predominantly to facial muscles
Secretomotor: lacrimal, submandibular, sublingual
Taste: anterior 2/3rd of tongue
Sensory: Post-aural / concha / ext. auditory canal
Course of facial nerve
Parts of facial nerve
Intracranial: within cerebello-pontine angle
Intra-temporal
Meatal segment Labyrinthine segment
Tympanic segment Mastoid segment
Extra-cranial
Extra-parotid Intra-parotid (terminal)
1. Supranuclear: Fibers in cerebral cortex to brain stem
2. Brain stem: Motor nucleus of facial nerve (pons)
3. Intra-cranial (12 mm): Brain stem to entry into IAC
4. Meatal (10 mm): Within Internal Auditory Canal
5. Labyrinthine (4 mm): Fundus of I.A.C. to Geniculate gangl.
6. Tympanic (11 mm): Geniculate ganglion to pyramid
7. Mastoid (13 mm): Pyramid to stylomastoid foramen
8. Extra-temporal (15 mm): S.M. foramen to pes anserinus
Segments of Facial Nerve
Primary branches of facial nerve
Intra-temporal: greater superficial petrosal,
stapedius, chorda tympani
Extra-parotid: post-auricular, stylohyoid, posterior
belly of digastric
Intra-parotid: temporal, zygomatic, buccal,
marginal mandibular, descending cervical
Intra-cranial branches
Extra-cranial branches
Communicating branches to:
Meatal: vestibulo-cochlear
Tympanic: lesser petrosal otic ganglion
Mastoid: auricular branch of vagus
Extra-parotid: glossopharyngeal, auriculotemporal,
vagus, greater auricular, lesser
occipital
Terminal: branches of trigeminal
Surgical landmarks
Cochleariform process: small bony protuberance
(from which tensor tympani muscle turns 900 to insert
into malleus) lies 1 mm inferior to geniculate ganglion
at anterior end of tympanic segment.
Cog: bony ridge hanging from tegmen tympani lies 1
mm above & posterior to cochleariform process.
Incus short process: 2 mm below lies external genu
Lateral Semicircular Canal: 2 mm Antero-Infero-
Medial lies external genu
Oval window: 1 mm above lies external genu
Inferior edge of Posterior S.C.C.: 2 mm anterior & lateral lies mastoid segment of facial nerve
Tympano-mastoid suture in posterior canal wall: 5-8 mm medial lies mastoid segment of facial nerve
Digastric ridge in mastoid tip: leads antero-medially to mastoid segment of facial nerve
Groove between mastoid & bony E.A.C. meatus: bisected by facial nerve
Tragal pointer: 1 cm antero-infero-medial is facial nv
Root of styloid process: lateral lies facial nerve
Superior border of posterior belly of digastric: superior & parallel lies facial nerve
Surgical landmarks
Lesions of Facial Nerve
Lesion ManifestationSupranuclear C/L hemiplegia, ed jaw jerk
Nuclear (pons) I/L 6th, 7th palsy + C/L hemiplegia
In C.P. Angle I/L 5th, 7th, 8th palsy
Supra-geniculate ed lacrimation, hyperacusis, loss of taste
Supra-stapedial Hyperacusis, loss of taste
Supra-chordal Loss of taste
Infra-chordal Facial asymmetry only
Features Upper Motor Neuron Palsy
Lower Motor Neuron Palsy
Forehead wrinkling B/L present Same side absent
Eye closure B/L present Same side absent
Naso-labial fold Opposite side absent
Same side absent
Drooping of angle of mouth
Opposite side Same side
Etiology of Facial Nerve Palsy
1. Idiopathic (55%): Bell’s palsy,
Melkersson Rosenthal syndrome
2. Temporal bone trauma (25%): Road traffic accident
3. Infection (10%): C.S.O.M., Herpes Zoster oticus
Malignant otitis externa
4. Neoplasm (5%): Parotid tumors, Acoustic Neuroma,
Glomus tumors, Malignancy of ear
5. Congenital (4%): Moebius syndrome
6. Iatrogenic (rare): Mastoidectomy, Parotid surgery
7. Metabolic (rare): Diabetes mellitus, Hypertension
Sunderland’s Classification (1951)
Cross section of nerve
Grade Name Characteristics
I Neuropraxia Partial block of axoplasm
II Axonotemesis Injury to axon
III Neurotemesis Injury to endoneurium or myelin sheath
IV Partial transection
Injury to perineurium
V Complete transection
Injury to epineurium
House Brackmann Classification (1 year
post-injury)
Grade Description Characteristics
I Normal Normal facial function
II Mild dysfunction
Slight weakness seen only on close inspection
III Moderate dysfunction
Obvious asymmetry; complete eye closure
IV Moderately severe dysfunction
Obvious asymmetry; incomplete eye closure
V Severe dysfunction
Only minimal motion seen; asymmetry at rest
VI Total paralysis No movement
Sunderland Grading
EEMG response
Recovery begins in
House Brackmann grading
I Normal 1-4 wks I
II 25 % of normal
1-2 mth II
III < 10 % of normal
2-4 mth III or IV
IV No response 4-18 mth V
V No response Never VI
Diagnosis Topo-diagnostic Tests
Electrical Tests
Magnetic stimulation of intra-cranial facial nerve
CT scan temporal bone: for progressive palsy
MRI brain
Surgical exploration
Topo-diagnostic tests Audiometry: cochlear nerve function
Vestibulometry: vestibular function
Schirmer’s test: Greater Superficial Petrosal Nerve
Stapedial reflex test: Nerve to stapedius
Electrogustometry: Chorda tympani
Submandibular salivary flow: Chorda tympani
Examination for terminal facial nerve branches
Schirmer’s Test
Unilateral wetness ed by
>30% of total amount of
both eyes after 5 minutes =
Schirmer test positive
lesion at or proximal to
geniculate ganglion
Stapedial Reflex
Electrogustometry Measures minimum amount of current
required to excite sensation of taste
Muscles supplied by terminal branches
Electrical tests
Nerve Excitability Test
Stimulating electrode used over terminal
branches of facial nerve
Minimum current intensity required to produce
minimal muscle movement is calculated
Normal side compared to paralyzed side
Difference > 3.5 mAmp = unfavorable prognosis
Maximal stimulation test
Stimulating electrode used over terminal
branches of facial nerve
Minimum current intensity required to produce
maximal muscle movement is calculated
Normal side compared to paralyzed side
Difference > 3.5 mAmp = unfavorable prognosis
Electro-neuronography
Terminal branch of facial nerve stimulated &
action potential recorded in appropriate muscle
Paralyzed side compared to normal side (which
is taken as 100%)
Response > 10% = 85-95 % chance of recovery
Response < 10% = 25 % chance of recovery
Electro-neuronography
Electro-neuronography
Electro-neuronography
ElectromyographyRecords spontaneous activity of facial muscles
Electromyography ResponsesNormal Polyphasic
Fibrillation Electrical Silence
Response Interpretation Normal Motor Unit Action Potentials:
Incomplete transection of facial nerve
Poly-phasic Motor Unit Action Potentials:
Re-
innervation of facial muscles
Fibrillation potentials:
Denervation of muscles (2-3
weeks after trauma)
Electrical silence:
Atrophy / absence of muscle
Bell’s Palsy Acute onset, idiopathic, unilateral, self-limiting,
non-progressive, peripheral facial nerve palsy
85% start recovering within 3 weeks
Etiology:
1. Viral: Herpes simplex, Herpes Zoster
2. Ischemia of facial nerve: exposure to cold,
emotional stress, nerve compression
3. Hereditary 4. Autoimmune
Sir Charles Bell
Clinical Features Loss of forehead wrinkles
Inability to close eyes
Wide palpebral fissure
Epiphora
Loss of naso-labial fold
Drooping of angle of mouth
Dribbling of food while
chewing on affected side
Medical treatment Prednisolone (1mg/kg in 2 doses): for 2 - 3 weeks
Acyclovir: 200-400 mg 5 times per day X 7days
Eye care: Voluntary closure @ 2 / min. Ciplox eye
drops 2 hourly & ointment H.S. Eye cover at night.
Physiotherapy: moist heat + facial massage +
facial muscle exercise
Electrical stimulation of facial nerve & muscle
Facial nerve decompression: Controversial
Moebius syndrome
Melkersson Rosenthal Syndrome
Recurrent alternating facial palsy
Fissured tongue
Facio-labial edema
Familial history
Melkersson Rosenthal Syndrome
Surgical Treatment for
Facial Nerve Injury
A. Facial nerve decompression: till meatal foramen
B. Neurorrhaphy (Nerve repair)
1. Direct end to end anastomosis
2. Interposition Cable grafting: sural, greater auricular
C. Nerve Transposition: hypoglossal-facial
D. Muscle Transposition: temporalis, masseter
E. Micro-neuro-vascular muscle flaps
F. Static Procedures: eyelid implant, fascial sling
Treatment ProtocolUp to 3 weeks:
Nerve decompression or Nerve
repair
3 weeks – 2 year:
Nerve Repair or Nerve
Transposition
> 2 year with fibrillation in Electromyography:
Nerve Repair or Nerve
Transposition
> 2 yr with electrical silence in Electromyography:
Muscle
transposition / Eyelid implant / Fascial sling
Facial Nerve Decompression Cortical mastoidectomy done
Facial nerve canal bone thinned in barber pole
fashion with diamond burr. Drilling done:
Posteriorly at mastoid segment, Laterally at
external genu & Inferiorly at tympanic segment
Avoids injury to chorda tympani & lateral S.C.C.
Labyrinthine segment decompressed by middle
cranial fossa approach
Barber Pole
Direct repair & Cable Grafting
Nerves used for cable grafting
Nerve Transposition
Nerve Transposition
Temporalis muscle transposition
Masseter muscle transposition
Gold Weight Eyelid Implant
Complications of facial nerve injury
1. Incomplete recovery 2. Exposure keratitis
3. Facial tics & spasms
4. Faulty regeneration of facial nerve
a. Synkinesis: Mass movement of facial muscles
b. Crocodile tear syndrome: gustatory lacrimation
Salivary to lacrimal gland cross over
c. Frey’s syndrome: gustatory sweating
Secreto-motor to sympathetic cross over
Thank You
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