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Facial Paralysis

Facial Nerve Subcommittee of the American Academy


of Otolaryngology-Head & Neck Surgery
Editor: Peter S Roland MD
Contributors: Peter S Roland MD, Larry Lundy MD, Jacques
Herzog MD, Fred Telischi MD & Gady Har-El MD
DISCLAIMER:
The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNS/F)
is providing these resources for historical purposes only. The information is provided AS IS, and
the Academy makes no representations or warranties about the suitability of this information for
any purpose. The information contained in this publication represents the views of those who
created it at the time it was created, and does not necessarily represent the official views or
recommendations of the American Academy of Otolaryngology — Head and Neck Surgery
Foundation, Inc. All materials are subject to copyrights owned or licensed by the AAO-HNS/F,
and all rights are reserved. The names, trademarks, service marks, and logos of the AAO-HNS/F
may not be used by any other party without prior, express written permission of AAO-HNS/F.

© 2003 The American Academy of Otolaryngology – Head and Neck Surgery Foundation
Facial Paralysis
Etiology

• Idiopathic 57%
• Trauma 17%
• Herpes zoster 7%
• Tumor 6%
• Infection 4%
• Birth trauma 3%
• Central etiology 1%

© 2003 The American Academy of Otolaryngology – Head and Neck Surgery Foundation
Bell’s Palsy and Ramsay-Hunt

• Ramsay-Hunt • Bell’s palsy


– Facial paralysis – Idiopathic and therefore a
– Otalgia diagnosis of exclusion
– Vesicular eruption on
auricle – Widely held to be viral
– Sensorineural hearing etiology
loss (SNHL) / Vertigo
– Varicella zoster virus

© 2003 The American Academy of Otolaryngology – Head and Neck Surgery Foundation
Diagnosis

• History and physical examination

• Audiometry

• Topognostic study

• Radiographic imaging

• Prognostic studies

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History

• Sudden or gradual

• Associated hearing loss


– Tinnitus
– Pain
– Infection
– Trauma Chronic Suppurative Otitis Media

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House-Brackmann Grading

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Physical
Otoscopy

• Hemotympanum
• Otitis media
• Cholesteatoma
• Middle ear mass
• Vesicular eruption
Middle ear paraganglioma

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Physical Examination
Neurological

• Facial nerve

– Incomplete vs. complete


– LMN vs. UMN

• Other cranial nerves

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Topognostic Testing

• Tear test

• Stapedial reflex

• Taste test

• Salivary flow

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Radiography
Air contrast CT

• Asymmetric SNHL

• Complete CN VII
palsy

• MRI/CT

Metastatic mass in
Internal Auditory Canal

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Etiology

• Viral
– Herpes simplex
– Herpes zoster

• Vasospasm

• Immunologic injury

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Pathophysiology

• Entrapment

• Compressive neuropathy

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Natural History
• Bell’s palsy • Ramsay-Hunt

– Total paralysis 69% – Greater degeneration


– Complete recovery 71% – Complete recovery 16%
– Satisfactory outcome 84% – Satisfactory 40-50%
– Recurrence 6.8%

Early return = Good prognosis

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Prognostic Studies
Identify within 14 days of onset

• Salivary flow

• Electrodiagnostic studies

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Prognostic Studies

• Identify reversible vs. irreversible injury

• Prevent progression from second-degree to


third-degree injury

• Timing 3-5 days

• ? Reinnervation

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Prognostic Studies
Poor prognosis

• Minimal excitability > 3.5 mAmps

• ENOG > 90% degeneration

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Treatment
Medical
• Prednisone 1 mg/kg/day X 5-14
days, slow taper

• Valcyclovir 1000 mg TID

• Famciclovir 500 mg TID

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Treatment
Surgical

• > 90% degeneration

• Within 14-21 days of onset

• Expose meatal foramen

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Electrophysiologic Testing

• Primary uses of testing

– Assists in prognosis

– Helps determine appropriate treatment options

– Monitors response to treatment

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Nerve Injury - Sunderland Classes

• 1st degree – Neuropraxia

• 2nd degree – Axonotmesis

• 3rd degree – Endoneural disruption

• 4th degree – Perineurial disruption


• 5th degree – Neurotmesis

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Electrophysiologic Testing
• Basic principles

– Facial nerve is tested distal to site of lesion

– Attempt to determine rate and degree of degeneration

– Need to assess facial nerve function frequently (daily


or every other day)

– Need normal function on uninvolved side for


comparison of test results

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Electrophysiologic Testing
• Basic principles (cont’d)

– Only valid for clinically paralyzed, not paretic,


facial nerve
– No value once response is lost or recovery
begins
– Test results lag behind pathologic event by
about 3 days

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Electrophysiologic Testing
• Test battery

– NET - Nerve excitability test

– MST - Maximal stimulation test

– ENOG - Electroneuronography

– EMG - Electromyography

© 2003 The American Academy of Otolaryngology – Head and Neck Surgery Foundation
Electrophysiologic Testing
• NET – Nerve excitability test

– Lowest level of stimulation to get a twitch


– Compare this threshold with normal-side
threshold
– Difference of 3.5 mAmps indicates significant
and progressive degeneration
– ~ 40% of patients with 3.5 mAmps difference
still have complete, spontaneous recovery

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Electrophysiologic Testing
• MST - Maximal stimulation test
– Increase stimulation level until maximal
response is seen
– Grade response (compared with normal side)
as:
• Equal
• Slightly decreased
• Markedly decreased
• Absent

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Electrophysiologic Testing
• MST - Maximal stimulation test (cont’d)

– If normal response for 10 days, then 85-90%


chance of complete return of function
– If markedly decreased or absent, then ~ 85%
chance of poor outcome with significant
sequela
– If response slightly or markedly decreases,
expect some synkinesis

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ENOG - Electroneuronography
• Uses maximal stimulation
• Record compound
muscle action potential
(CMAP)
• Measure amplitude of
response
• Amplitude of waveform is
proportional to number of
functional axons

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ENOG -Electroneuronography
• If amplitude of involved side is 10% or less than
normal side, then poor chance for spontaneous
normal or near normal recovery
• If amplitude of involved side is 10% or greater than
normal side, expect excellent recovery

NORMAL ABNORMAL LEFT

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Electrophysiologic Testing
• EMG – Electromyography

– Requires needle insertion into facial muscles

– Need to test multiple muscle groups (3-5


recommended)

– Does not estimate percentage of degenerated


facial nerve fibers

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Electrophysiologic Testing
• EMG – Electromyography
– Primary use in acute phase of facial paralysis (first
2 weeks) is confirmatory for other tests

– If other tests (NET, MST, ENOG) show no or little


response, and EMG shows voluntary motor unit
potentials, then still have good prognosis

– Loss of voluntary motor unit potentials worsens


prognosis

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Electrophysiologic Testing
• EMG - Electromyography (cont’d)

– Fibrillation potentials occur at earliest at 10-14 days


post onset, indicating degenerating motor units

– Polyphasic reinnervation potentials can occur as early


as 4-6 weeks post onset, indicating fair recovery (if
later, worse recovery)

© 2003 The American Academy of Otolaryngology – Head and Neck Surgery Foundation
Facial Paralysis Secondary to Otitis Media

• Acute otitis media

• Chronic suppurative
otitis media

• Cholesteatoma
Acute Otitis Media

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Acute Otitis Media
• Pathophysiology:
– Natural dehiscences?? Hof has localized “block” to
dehiscence in 2 cases but 55% of t-bones have
dehiscences

– Bacteriology no different than for acute otitis media

– Direct involvement of the facial nerve by infection.


(Balance and Duel, 1932; May, 1982)

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Acute Otitis Media
• Pathophysiology:

– Demyelination secondary to bacterial


toxins (Kettle, 1943; Joseph and Sperling, 1998)
– Ischemia secondary to thrombosis of the
vaso-vasorum (Antoni-Candela and Stewart, 1974; Graham,1977)
– Viral reactivation ( Joseph and Sperling, 1998)
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Acute Otitis Media
• Clinical reports: Ellefsen

– 23 patients
– 12 presented with moderate palsy and 11
with severe
– 4 had mastoidectomy secondary to
persistent infection @ 2-4 weeks
– 22/23  HB I. Onset of improvement
within 3 weeks in 78%

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Acute Otitis Media
• Clinical reports: May

– 36 cases
– 89% good recovery, 11% poor
– All Rxed with
antibiotics (abx) + myringotomy (myr)
– Surgery if complete paralysis plus no response to
maximal stimulation or  salivary flow or coalescent
mastoiditis or meningitis
– Maximal stimulation testing predicted recovery

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Acute Otitis Media
• Clinical reports: Elliot

– 10 cases, 8 patients incomplete and 2


complete

– 8/8 incomplete recovered with abx + myr


(1 protracted)

– The 2 complete had mastoidectomy and


recovered

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Acute Otitis Media
• Clinical reports: Hof

– 7 pts

– 5 recovered with abx + myr + tube

– 2 had mastoidectomy with decompression


secondary to facial nerve FN deterioration,
both recovered

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Acute Otitis Media
• Incidence in preantibiotic era:

– 4 estimates by separate investigators all


between 0.5% and 0.7%

• Incidence in postantibiotic era:


– 2 estimates by separate investigators
between 0.005% and 0.16%

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Acute Otitis Media
• Clinical reports: Bluestone
– 35 cases
– 22 partial and 13 complete
– All Rxed with abx + myr
– 7 needed surgery because of
coalescent mastoiditis or ENOG
evidence of denervation

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Recommendations
• Consensus:

– Facial nerve paralysis secondary to acute


otitis media should be Rxed with appropriate
antibiotics

– Myringotomy if not already draining

© 2003 The American Academy of Otolaryngology – Head and Neck Surgery Foundation
Recommendations
• Debated:
– A tube should be inserted
– Electrophysiological tests should be
used to determine if surgery is
necessary
– Decompression should accompany
mastoidectomy
– Steroids

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Chronic Suppurative Otitis Media

• Incidence:

– Preantibiotic
• 2.3% (Pollock)

– Postntibiotic
• May — 3 cases
• Harker — 5 cases
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Chronic Suppurative Otitis Media

• Pathophysiology:

– Natural dehiscence ??

– Many of the same inflammatory


mediators found in cholesteatomas are
found in chronic suppurative otitis media

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Chronic Suppurative Otitis Media

• Clinical reports: Harker

– 6 ears
– 4 partial, 2 complete
– Surgery within 10 days after onset

– 5 recovered to HB I and 1 to HB II

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Chronic Suppurative Otitis Media
• Clinical reports: Hartley

– 1 case

– Immunosuppressed

– Required graft

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Cholesteatoma
• Incidence:

– May: 13 ears over


20 yrs

– Sheehy: 1.0% of
1,024 Primary ear
operations

– Hof: 2 cases in 3
yrs

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Cholesteatoma

• Pathophysiology:

–Pressure
–Inflammation

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Cholesteatoma
• Clinical reports:

– May: 7 pts with normal electrophysiology  HB I pt


with no response max. stimulation  all had
incomplete recoveries

– Magliulo: 10 pts with facial paralysis secondary to


very large cholesteatomas. 7 had grafts, 1 7-12. 2
had compression only — partial recovery

© 2003 The American Academy of Otolaryngology – Head and Neck Surgery Foundation
Recommendations
• CONSENSUS:

– Urgent surgical intervention is the most


appropriate therapy for facial nerve paralysis
secondary to cholesteatoma or chronic
suppurative otitis media

• DEBATED:

– CWU versus CWD; decompression

© 2003 The American Academy of Otolaryngology – Head and Neck Surgery Foundation
Facial Nerve Trauma
General considerations

• Most commonly injured cranial nerve

• Protected by longest bony nerve canal


• Second leading cause of facial paralysis after
Bell’s palsy
• Location (intra- vs. extratemporal facial nerve)
• Timing of paralysis

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Facial Nerve Trauma
Iatrogenic injury

• Anticipated or not
• Knowledge of anatomy
• Intraoperative monitoring
• Local anesthetic effects
• Early exploration

• ENOG for delayed paralysis

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Facial Nerve Trauma
Diagnosis

• Mechanism of injury

• Paralysis vs. paresis (HB grading scale)

• Immediate vs. gradual paralysis


• Electrical testing

• Imaging

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Facial Nerve Trauma
Temporal Bone Fracture
• Occipital or temporal impact

• Associated findings
• Hearing loss
• Cerebrospinal fluid (CSF)
otorrhea
• Mastoid ecchymosis (Battle’s
sign)
• Hemotympanum
• External canal disruption

Fracture through mastoid cortex

© 2003 The American Academy of Otolaryngology – Head and Neck Surgery Foundation
Facial Nerve Trauma
Temporal Bone Fracture
• High-resolution CT

• Transverse vs. longitudinal orientation

• Mechanisms of injury
• Stretch (50%)
• Transection (30%)
• Compression (20%)

© 2003 The American Academy of Otolaryngology – Head and Neck Surgery Foundation
Temporal Bone Fracture

Transverse

Longitutdinal

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Longitudinal Fractures

• 4 times more common than


transverse
• Facial nerve injury in 20% of
cases
• Stretch or bony compression
more common
• Perigeniculate area most
common site
• Conductive hearing loss typical Longitudinal fracture

© 2003 The American Academy of Otolaryngology – Head and Neck Surgery Foundation
Transverse Fractures

• Frequent severe brain


injury/mortality
• 50% associated with facial
nerve injury
• Labyrinthine segment most
common site
• Transection common
• Sensorineural hearing loss
typical
Transverse fracture

© 2003 The American Academy of Otolaryngology – Head and Neck Surgery Foundation
Facial Nerve Trauma
Electrophysiologic Testing
• Paralysis only

• After 3 days
• ENOG appears most accurate initially

• EMG during recovery for prognostication

• Nerve conduction for peripheral injuries

© 2003 The American Academy of Otolaryngology – Head and Neck Surgery Foundation
Facial Nerve Trauma
Temporal Bone Fracture
• Steroids

• Decompression
• Exploration
• Removal of bone fragments

• Neurorrhaphy

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Penetrating Injuries

• Early exploration
• Neurorrhaphy
• Grafting
• Mobilization
• >30-50% injury
Bullet lodged in Temporal Bone

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Facial Nerve Trauma
Repair Technique
• No tension (grafting when necessary)

• As soon as possible
– Barring infection/contamination

• Fresh nerve endings

• Approximation in fallopian canal or with


several sutures

© 2003 The American Academy of Otolaryngology – Head and Neck Surgery Foundation
Facial Rehabilitation
after Facial Nerve Paralysis
• Total facial rehabilitation – neural
procedures

• Segmental rehabilitation

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Neural Procedures
(nerve-muscle junction must be functionally intact)

• Primary neurorrhaphy (+ rerouting)

• Cable grafting

• Crossover procedures

• Cross-face nerve grafts

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Prereanimation/After interposition graft

Prereanimation After interposition graft

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Nerve Crossover
• Distal nerve function?
• Neuromuscular junction function?
• Muscle atrophy?

Types
• Hypoglossal - Facial
• Spinal accessory - Facial
• Phrenic - Facial

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1 year After 12-7 Crossover

1 yr after 12-7 crossover

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Rehabilitation By Site

• Upper face

• Midface

• Lower face

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Exposure Keratitis

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Upper Eyelid
• Tarsorrhaphy
• Gold weight
• Spring
• Cartilage
• Blepharoplasty
• Silastic encircling
• Temporalis muscle transposition
• Free muscle transfer
(+ Cross-face nerve graft)

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Gold Weight

Gold weight
Intraop after surgery Good eye closure post-op

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Lower Eyelid

• Tarsorrhaphy
• Lid shortening
• Lateral canthoplasty
• Medial canthoplasty (+ adhesion)
• Cartilage graft augmentation
• Temporalis muscle transposition
• Free muscle transfer

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Lid Shortening/Canthoplasty

Lid shortening Canthoplasty

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Eyebrow

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Midface

• Cosmesis
• Breathing
• Static
• Dynamic

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Dynamic Midface
Rehabilitation

• Temporalis muscle transfer

• Masseter muscle transfer

• Cross-face nerve graft

• Free muscle transfer

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Static Midface
Rehabilitation
• Facelift
• Suspension procedures (fascia, palmaris
longus, Alloplastic materials)
• Rhinoplasty
• Nasal valve reconstruction (+ grafts)
• Alar suspension to orbital
• Springs, dilators

© 2003 The American Academy of Otolaryngology – Head and Neck Surgery Foundation
Dynamic Lower Face Rehabilitation

• Temporalis muscle transfer


• Masseter muscle transfer
• Digastric muscle (anterior belly) transfer
• Free muscle transfer
• Cross-face nerve graft

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The Lower Face/Smile

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Before and After Temporalis Muscle Transfer Procedure

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Static Lower Face Rehabilitation
• Facelift
• Oral commissuroplasty (primary, secondary)
• Lip wedge resection
• Suspension procedures
(fascia, tendon, Alloplastic materials)

• Anti-drooling procedures

© 2003 The American Academy of Otolaryngology – Head and Neck Surgery Foundation

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