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Facial Paralysis Lecture Ready2

Facial Paralysis Lecture Ready2

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Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

‫بسم الله الرحمن الرحيم‬

‫ومن‬ ‫خير‬

‫يؤتى الحكمة من يشاء‬ ‫يؤت الحكمة فقد أوتى‬ ‫اكثيرا‬

‫صدق الله العظيم (البقرة 962)‬

‫الحكمة: القدرة على الفهم و التمييز‬ ‫)و الصابة فى القول والفعل (الطبرى‬

Facial nerve paralysis
by M. Hisham Hamad Prof. Otolaryngology Tanta University

Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

Problem solving and MCQ Questions

Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

•What is the lesion? •Side)Rt or Lt( •Site )U or lower(

Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

• This gentleman presented with right severe otalgia and drippling of saliva from the right side of the mouth with collection of food in the right cheek during meals. No
other associated symptoms or sign were noted.

Problem solving

• What is the most probable diagnosis?

Prof. Hisham Hamad

• This gentleman is 50 ys old presented with one day history of “my face isn’t moving”
– Occurred overnight – No ear pain, previous viral illness – No hearing loss – No prior history, no family history – No other associated symptoms

Problem solving

• 4 weeks he started to feel some movement in his face.

Prof. Hisham Hamad

• Recurrent Facaial paralysis occurning few days after onset of acute otitis media denotes A.Bulging tympanic membrane B.mastoiditis C.Congenital anomaly of the ear D.Immunodefiency
Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

• Bells balsy is commonly treated with: A. B. antihistaminic and steroids antihistaminic and antiviral

C. antiviral And steroids D. antibiotic and steroids
Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

• Progressive unilateral LMN Facaial paralysis over more than 3 monthes without identified aetiology is most probably due to A. Bell s balsy B. Brain tumor in motor area of temporal lobe C. Acoustic nerve neuroma D.Malignant otitis externa
Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

Anatomy
origin
3 nuclei motor sup salivary T solitarius Mixed nerve Gen Motor Secretomotor Gen Sensory Sp sensory )taste(
Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

Anatomy
origin
3 nuclei motor sup salivary T solitarius

Mixed nerve Gen Motor Secretomotor Gen Sensory Sp sensory (taste)
Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

Anatom y
distributio n

Mixed nerve General Motor Secretomotor General Sensory Special sensory )taste(
Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

Anatom y

Mixed nerve

Motor muscles of facial expression
Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

Anatom y
Mixed nerve Secretomotor lacrimal gl submandibular sublingual

Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

Anatom y
Mixed nerve Secretomotor lacrimal gl submandibular sublingual

Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

Anatom y
Mixed nerve Special sensory

tase ant 2/3 of tongue

Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

Anatom y
Mixed nerve General sensory

concha & ext canal

Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

Motor
UMN
pyramidal extra-pyramidal emothional movement Prof. Hisham Hamad
bilateral to upper face

LMN

Copyright, 1996 © Dale Carnegie & Associates, Inc.

Motor
UMN
pyramidal bilateral to upper face extra-pyramidal emothional movement
Copyright, 1996 © Dale Carnegie & Associates, Inc.

LMN

Prof. Hisham Hamad

Motor
UMN

pyramidal extra-pyramidal
voluntary movement emothional movement

Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

Motor
UMN
suranuclear pyramidal extra-pyramidal

LMN
nuclear infranuclear

Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

UMNL # LMNL
Site of lesion Side of paralysis Emotional movement Upper face movement Type of lesion Sequallae of paralysis Bell s phenomenon Associates
Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

UMNL # LMNL

Flaccid paralysis

Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

UMNL # LMNL

Sequallae of paralysis

Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

UMNL # LMNL

Bell s phenomenon

Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

Motor lesion level UMN LMN
supranuclear Δ extra Δ

nuclear CPA meatal lanyrinthine horizontal tympanic vertical mastoid SM foramen peripheral
Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

Motor
LMN
nuclear CPA meatal

Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

Motor
LMN
nuclear CPA meatal lanyrinthine

Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

Motor

LMN
nuclear CPA meatal lanyrinthine

Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

Motor
LMN
nuclear CPA lanyrinthine horizontal tympanic

Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

Motor
LMN
nuclear CPA meatal lanyrinthine horizontal tympanic vertical mastoid

Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

Motor
LMN
nuclear CPA meatal lanyrinthine horizontal tympanic vertical mastoid SM foramen

Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

Motor
LMN
nuclear CPA meatal lanyrinthine horizontal tympanic vertical mastoid SM foramen peripheral

Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

Motor
LMN
nuclear CPA meatal lanyrinthine horizontal tympanic vertical mastoid SM foramen peripheral

Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

Relations & LMN branches nuclear )6 N(
th

N(

CPA )cerebellum & N intermedius & 8TH meatal )8th N(

LMN branches level
greater petrosal N to stapedius chorda tympani peripheral

Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

Motor dysfunction hypokinetic hyperkinetic blepherospasm & facial tics hemifacial spasm facial myokymia focal siezure synkinesia tic doulaureux )trigeminal nueralgia( Autonomic crocodile tears sphenopalatine neuralgia Sensory herpes zoster otalgia Bell s palsy taste disturbance

Disorders of the facial nerve

Pathophysiology

Idiopathic

Traumatic Inflammatory neoplastic
Copyright, 1996 © Dale Carnegie & Associates, Inc.

mostly viral

Prof. Hisham Hamad

Pathophysiology

Neuropraxia Axontemesis neurotmesis
Prof. Hisham Hamad

Copyright, 1996 © Dale Carnegie & Associates, Inc.

Sunderland classification of peripheral nerve injury
Neurapraxia

Axonotmesis

Neurotmesis

Pathophysiology
Wallerian degeneration Absent in
neuripraxia

Occurs in

axontemesis neurontesis

Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

Pathophysiology
Wallerian degeneration Absent in
neuripraxia

Occurs in

axontemesis neurontesis

Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

Pathophysiology

Neuropraxia Axontemesis neurotmesis
Prof. Hisham Hamad

Copyright, 1996 © Dale Carnegie & Associates, Inc.

Pathophysiology Regeneration Intact sheath Disrupted sheath
good recovery failure )residual paralysis + atrophy( misdirection to other muscles)synkinesia( taste to lacrimal gland )crocodile tears( parotid fibres to sweat glands )frey syn to other axons)short circuiting(
Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

TESTS OF THE FACIAL NERVE

Site of lesion)topognostic( Electrodiagosis )prognostic(
Prof. Hisham Hamad

Copyright, 1996 © Dale Carnegie & Associates, Inc.

TESTS OF THE FACIAL NERVE
Site of lesion)topognostic( 1-G petrosal N schirmer test 2-N to stapedius stapedial reflex 3-chorda tympani a(taste gustometry b(salivary flow 5-peripheral brabches segmental facial movement
Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

TESTS OF THE FACIAL NERVE
Site of lesion)topognostic( 1-G petrosal N schirmer test 2-N to stapedius stapedial reflex 3-chorda tympani a(taste gustometry b(salivary flow 5-peripheral brabches segmental facial movement
Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

Topognostic Test
• Lacrimal
– Schirmer’s Test

• Stapedial reflex • Taste • Salivary flow

TESTS OF THE FACIAL NERVE Electrodiagosis )prognostic(
1-nerve excitability test 2-strength duration curve 3--maximal N stimulation test 4 electromyography 5-electroneurography
the most informative
Copyright, 1996 © Dale Carnegie & Associates, Inc.

3.5 mA difference is significant

normal, partial or denervation curves

voluntary,fibrillation denervation or polyphasic reinnervation potentials

Prof. Hisham Hamad

TESTS OF THE FACIAL NERVE

Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

TESTS OF THE FACIAL NERVE
Electroneurography
the most informative quantitative

Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

Diagnosis
Paralysed or not? Where is the lesion? How much is the degeneration? What is the lesion?
Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

1-Paralysed or not? Clinical picture

At rest Voluntary movement Emotional movement
Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

Clinical picture
At rest
)Due to unoppoesd pull of active muscles(

Loss of Forhead whrinkes Nasolabial fold Dead wide Eye Mouth Dropped angle Shortened on active

side

drippling from angle
Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

Clinical picture
  

Voluntary movement
During eating During talking ask him to Whrinkle forehead Raise eyebrow Close the eye Show your teeth Blow your cheek To whistle

Emotional movement Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.

Clinical picture

During Close the Blow the Show th voluntary eyes teeth cheek movement

Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

2-Where is the lesion
UMNL or LMNL LMNL what level
nuclear CPA meatal at geniculate( suprapyramidal infrapyramidal at stylomastoid F extratemporal
Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

UMNL # LMNL
Site of lesion Side of paralysis Emotional movement Upper face movement Type of lesion Sequllae of paralysis Bell s phenomenon
Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

2-Where is the lesion
UMNL or LMNL LMNL what level
nuclear CPA meatal at geniculate( suprapyramidal infrapyramidal at stylomastoid F extratemporal
Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

2-Where is the lesion
UMNL or LMNL LMNL what level
nuclear CPA meatal at geniculate( suprapyramidal infrapyramidal at stylomastoid F extratemporal
Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

2-Where is the lesion
UMNL or LMNL LMNL what level
nuclear CPA meatal at geniculate( suprapyramidal infrapyramidal at stylomastoid F extratemporal
Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

2-Where is the lesion? topognostic tests
1-G petrosal N schirmer test 2-N to stapedius stapedial reflex 3-chorda tympani a(taste gustometry b(salivary flow 5-peripheral brabches segmental facial movement
Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

UMNL or LMNL LMNL

2-Where is the lesion
nuclear )6th N+ hemiplegia + all Normal( CPA )cerebellum+ 8TH N + N intermedius( meatal )No celebellar( at geniculate)No 8TH N( tympanic )Normal tearing( mastoid )Normal tearing & N at stylomastoid F )all Normal( extratemporal )segmental(
Copyright, 1996 © Dale Carnegie & Associates, Inc.

AR(

Prof. Hisham Hamad

degeneration
Degree does not matter Incomplete paralysis always recovers well Complete paralysis recovers well if neuropraxic if degeneration is less than 90%
Copyright, 1996 © Dale Carnegie & Associates, Inc.

3-How much

Prof. Hisham Hamad

degeneration
Elecrodiagnostic tests Elecroneurography test

3-How much

IS THE MOST VALUEBLE QUANTITATIVE 90 % or less degeneration denotes poor recovery

Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

4-What is the lesion? Idiopathic
Inflammatory Traumatic F base, forceps cut wound Iatrogenic brain, ear, parotid Neoplastic primary 2ndary Toxic metabolic
Copyright, 1996 © Dale Carnegie & Associates, Inc.

malig OE AOM, A mastoiditis ch OM, H zoster

Prof. Hisham Hamad

4-What is the lesion? Idiopathic
Inflammatory Traumatic F base, forceps cut wound Iatrogenic brain, ear, parotid Neoplastic primary 2ndary Toxic metabolic
Copyright, 1996 © Dale Carnegie & Associates, Inc.

malig OE AOM, A mastoiditis ch OM, H zoster

Prof. Hisham Hamad

4-What is the lesion? Idiopathic
Inflammatory Traumatic F base, forceps cut wound Iatrogenic brain, ear, parotid Neoplastic primary 2ndary Toxic metabolic
Copyright, 1996 © Dale Carnegie & Associates, Inc.

malig OE AOM, A mastoiditis ch OM, H zoster

Prof. Hisham Hamad

Complications
Psychological Drooling Eye complications exposure keratitis infection )up to panophthamitis( Persistent paralysis Tics & spasm Atrophy & contracture Crocodile tears Frey syndrome
Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

Of the cause

Treatment:

Avoid complication

Avoid complication eye muscle atrophy residual paralysis Treat established complications residual paralysis crocodile tears $ gustatory sweating
Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

Treatment:

Avoid complication

Of the cause
antibiotic in malignant OE Acyclovir if viral )H zoster & Bell s( myringotomy if early in AOM mastoidectomy if late in AMO mastoidectomy if in chronic MO
Avoid complication Treat established complications
Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

Of the cause

Treatment:
eye

Avoid complication

Avoid complication
glasses artificial tears & ointment & dark tarsorraphy or gold weight

implant muscle atrophy adhesive tape phsiotherapy )passive $ active( residual paralysis medically steroid surgical if more than 90% deg decompression reanastonosis grafting

Treatment:

Avoid complication

Treatment: Surgery Guidelines
If partial If complete tests degeneration No surgery do elecrodiagnosis till till recovery 90%

 if more than 90% degeneration do decompression )partial injury( reanastomosis )complete injury( nerve grafting )tissue loss(

Treatment: eye
Avoid eye complication
artificial tears ointment tarsorraphy gold weight implant

Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

Prof. Hisham Hamad

Gold weight implanta tion

Treatment: Avoid complication Of the cause Avoid complication
Treat established complications
residual paralysis reanimation )if irreversible( dynamic graft facio-facial )cross face( hypoglossal to facial free micro-neurovascular static )sling( facia lata temporalis muscle masseter muscle crocodile tears $ gustatory

Dynamic reanimatiom graft facio-facial )cross face(

hypoglossal to facial
Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

Dynamic reanimatiom free micro-neuro-vascular

Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

static reanimatiom

Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

Bell s palsy
Definition:: idiopathic+ unilateral+ LMNL of the facial nerve Aetiolgy: Idiopathic Ischeamia primary )cold( 2ary)viral or autoimmune( Polymerase chain reaction )PCR( have demonstrated herpetic infection in most of the ceses. A better term is viral or herpetic facial paralysis.

Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

Diagnosis:

Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

Treatment:

prognosis

Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

Treatment:

No treatment for partial paralysis Complete paralysis give : Cortisone Acyclovir VD ?? + neurotropic vitamins ?? Surgical decompression if degeneration exceeds 90% physiotherapy afterv 2 weeks dark glasses + eye ointment +adhesive tapes Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.

Problem solving and MCQ Questions

Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

•What is the lesion? •Side)Rt or Lt( •Site )U or lower(

Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

•What is the lesion? •Side)Rt or Lt( •Site )U or lower(

Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

•What is the lesion? •Side)Rt or Lt( •Site )U or lower(

Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

•What is the lesion? •Side)Rt or Lt( •Site )U or lower(

Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

• This gentleman presented with right severe otalgia and drippling of saliva from the right side of the mouth with collection of food in the right cheek during meals. No
other associated symptoms or sign were noted.

Problem solving

• What is the most probable diagnosis?

Prof. Hisham Hamad

• This gentleman is 50 ys old presented with one day history of “my face isn’t moving”
– Occurred overnight – No ear pain, previous viral illness – No hearing loss – No prior history, no family history – No other associated symptoms

Problem solving

• 4 weeks he started to feel some movement in his face.

• What is the most probable diagnosis?

Prof. Hisham Hamad

• Recurrent Facaial paralysis occurning few days after onset of acute otitis media denotes A.Bulging tympanic membrane B.Mastoiditis C.Congenital anomaly of the ear D.Immunodefiency
Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

•Bells balsy is commonly treated with: A( antihistaminic and steroids B( antihistaminic and antiviral C( antiviral And steroids D( antibiotic and steroids
Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

•Progressive unilateral LMN Facaial paralysis over more than 3 monthes without identified aetiology is most probably due to •A( Bell s balsy

•B( Brain tumor in motor area of temporal tempora lobe •C Acoustic nerve neuroma •D( Malignant otitis externa

Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

1. Most prescribe steroids. The benefit is controversial. Conversely, 60mg of Prednisone for 7-10 days has only minor risks 2-The prognosis is so poor for Herpes Zoster Oticus cases that specialty consultation is required for patient satisfaction )that all possible was done( and for the PCP's medical legal protection. 3-Possible Lyme disease in endemic areas
Copyright, 1996 © Dale Carnegie & Associates, Inc.

Prof. Hisham Hamad

Prof. Hisham Hamad

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