Imaging in Acute Facial Nerve Paralysis

M Castillo, MD, FACR

Department of Radiology University of North Carolina, Chapel Hill

Overview of Presentation
Introduction Review of facial nerve anatomy Clinical and Imaging features of Bells palsy Typical Atypical Other causes of acute facial paralysis

Introduction
Bells palsy accounts for 75% of cases of acute facial nerve (7th cranial nerve) paralysis Imaging is not needed in majority of patients unless they have atypical features W/atypical features, MR & CT may demonstrate potentially treatable lesions affecting facial nerves Facial nerves can be affected anywhere along their course

Anatomy Review
Facial nerve nuclei lie in reticular formation of brainstem, ventral to floor (tegmentum) of 4th ventricle(4) Motor Nuclei:
Efferent fibers surround nuclei of CN VI & form small mounds on floor of 4th ventricle (facial colliculi)

Facial colliculus

Non-Motor Nuclei:
Salivatory Solitary

 Efferent fibers surround 6th CN nucleus & exit at cerebellopontine angle (CPA) 7th nerve courses into internal auditory canal (IAC)
Within superior anterior quadrant(6)

Ant

Post

Fallopian Canal

Exits IAC via Fallopian canal

Narrowest point throughout entire course Felt to be culprit in facial nerve compression in Bells palsy & other causes of nerve swelling

Geniculate ganglion

Progress to geniculate ganglion

Gives rise to greater superficial petrosal nerve
Contains taste axons from tongue & somatic fibers

 Fibers then course posteriorly under lateral semicircular canal in middle ear (tympanic portion) Fibers angle back & inferiorly at second genu diving the descending canal
Here last somatic & parasympathetic fibers separate from facial nerve via the chorda tympani nerve

Mastoid segment

Tympanic Portion

 Facial nerve exits skull base at stylomastoid foramen Facial nerve angles superiorly & anteriorly behind posterior margin of vertical mandibular ramus
Just before entering parotid gland, inferior branches originate
Posterior auricular, digastric & stylohyoid

Within substance of parotid gland, superior branches arise

Temporal, zygomatic, buccal, orbicularis oris, mandibular & cervical

Clinical Signs Suggesting Site of Facial Nerve Lesion

Upper facial territory is supplied by bilateral motor cortices Lower facial territory is supplied only by contralateral motor cortex Therefore, unilateral central lesions spare upper face Lesions distal to geniculate ganglion
Mostly motor abnormalities

Lesions proximal to geniculate ganglion

Motor, gustatory & autonomic abnormalities

Typical Bells Palsy

Incidence
1530 per 100,000 Usually during winter

Etiology not entirely understood

Possibly viral (Herpes Simplex Virus) or idiopathic

Viral infection of facial nerve results in demyelination, inflammation & swelling

Traps nerve in narrow confines of fallopian canal

Diagnosis of exclusion
Made only when clinical & imaging (if necessary) findings are supportive

Typical Bells Palsy

Usually a clinical diagnosis
Acute onset unilateral (lower or upper) facial paralysis, posterior auricular pain, decreased tearing, hyperacusis (30%) & disturbances of taste By physical examination, Bells palsy divided according to classification by House and Brackman
Grades 1 & 2 have better outcomes with worse outcome as grade increases.

80-90% recover completely

Over age 60, only 40% recover completely

Imaging in Typical Bells Palsy

Imaging in typical Bells palsy is not usually necessary
When necessary, MRI is best

Normal facial nerve distal to geniculate ganglion may enhance

Facial nerve proximal to geniculate ganglion does not normally enhance

In patients with Bells palsy, enhancement of facial nerve in fallopian & ICA is typical

C/o Dr. M. Michel, Wisconsin

Atypical Bells Palsy

Clinical features
Slower onset of symptoms Bilateral Recurrence

Numbness is not unusual Progression beyond seven days suggests another cause

Imaging in Atypical Bells Palsy

C/o Dr. M. Michel, Wisconsin

Alternative Causes of Acute Facial Nerve Paralysis

Atypical signs & symptoms which suggest etiology other than Bells palsy require imaging Clinical history is crucial in distinguishing etiologies Choice of imaging technique depends on clinical suspicion

Lyme Disease
Lyme disease (borreliosis)
Endemic areas (Northeast USA, central Europe, Scandinavia, Canada) Consider in children w/atypical facial palsy

Imaging: small white matter lesions similar to multiple sclerosis, enhancement of facial & other cranial nerves Bilateral facial paralysis: 25% Important to make diagnosis early because it is curable early w/antibiotics

Ramsay Hunt Syndrome

Caused by reactivation varicella zoster virus (herpes virus type 3) Facial paralysis + hearing loss +/- vertigo
Herpes zoster oticus

Two-thirds of patients have rash around ear Other cranial nerves, particularly trigeminal nerves (5th CN) often involved Worse prognosis than Bells (complete recovery: 50%) Important cause of facial paralysis in children 6-15 years old

C/o Dr. M. Michel, Wisconsin

Infectious causes
Acute facial paralysis may result from bacterial or tuberculous infection of middle ear, mastoid & necrotizing otitis externa Incidence of facial paralysis with otitis media: 0.16%
Infection extends via bone dehiscences to nerve in fallopian canal leading to swelling, compression & eventually vascular compromise & ischemia

Immune compromised patients are at risk for pseudomona infection Poor prognosis (complete recovery is < 50%)

Tuberculosis

Parotid & peri-parotid disease

HIV Infection

Bezolds abscess & coalescent mastoiditis

Trauma
Most acute post traumatic facial palsies are due to t-bone fractures Historically fractures classified as longitudinal or transverse with transverse carrying risk of permanent paralysis
Longitudinal fracture usually leads to temporary paralysis from concussion & swelling of nerve Transverse fracture can lead to transection of nerve

In all types of paralysis due to fracture, usually the region of geniculate ganglion is involved

Neoplasms
27% of patients with tumors involving the facial nerve develop acute facial paralysis Most common causes: schwannomas, hemangiomas (usually near geniculate ganglion) & perineural spread such as with head and neck carcinoma, lymphoma & leukemia Other neoplasms can also involve the facial nerve
Adults: metatstatic disease, glomus tumors, vestibular schwannomas & meningiomas Children: eosinophilic granuloma & sarcomas

Hemangioma

Hemangioma

Facial Nerve Schwannoma

Perineural Tumor Spread

Glomus Tumor
Glomus tumors arising from jugular bulb (jugulare) and/or middle ear (tympanicum) may involve the facial nerve

Other tumors

Rhabdomyosarcoma & squamous cell carcinoma of the EAC

Vestibular Schwannoma
Common tumor
However, facial nerve is resistant to compression
Therefore, tends to produce facial paralysis mostly when they attain a large size

Vestibular Schwannoma

Common tumor -However, facial nerve is resistant to compression, thus, tends to produce facial paralysis mostly when they attain a large size
-

Meningioma
Second most common primary tumor of cerebellopontine angle Rarely results in facial paralysis

Rhabdomyosarcoma

Miscellaneous Causes

Hypertrophic Polyneuropathy
Hypertrophic polyneuropathies occasionally lead to facial paralysis

Wegeners Granulomatosis

Other Causes
Guillain-Barre Syndrome Ascending paralysis Iatrogenic Temporal bone surgery Excision of vestibular schwannoma has <10% chance of paralysis Middle ear surgeries Babies who required forceps delivery >90% recovery

Melkersson-Rosenthal Syndrome
Acute episodes of facial paralysis Facial swelling Fissured tongue Scrotal tongue Very rare Familial but sporadic Usually begins in adolescence Leads to facial disfigurement No definite therapy

Conclusion
While Bells palsy does not typically require imaging for diagnosis, imaging evaluation is important in the work-up of patients with atypical or unusual presentations of acute facial nerve paralysis, identification of discreet lesions may lead to a change in management of these patients.