Professional Documents
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© 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
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Diagnosis
• Audiometry
• Topognostic study
• Radiographic imaging
• Prognostic studies
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History
• Sudden or gradual
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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
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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
© 2003 The American Academy of Otolaryngology – Head and Neck Surgery Foundation
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
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Prognostic Studies
Identify within 14 days of onset
• Salivary flow
• Electrodiagnostic studies
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Prognostic Studies
• ? Reinnervation
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Prognostic Studies
Poor prognosis
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Treatment
Medical
• Prednisone 1 mg/kg/day X 5-14
days, slow taper
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Treatment
Surgical
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Electrophysiologic Testing
– Assists in prognosis
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Nerve Injury - Sunderland Classes
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Electrophysiologic Testing
• Basic principles
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Electrophysiologic Testing
• Basic principles (cont’d)
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Electrophysiologic Testing
• Test battery
– ENOG - Electroneuronography
– EMG - Electromyography
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Electrophysiologic Testing
• NET – Nerve excitability test
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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)
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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
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Electrophysiologic Testing
• EMG – Electromyography
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Electrophysiologic Testing
• EMG – Electromyography
– Primary use in acute phase of facial paralysis (first
2 weeks) is confirmatory for other tests
© 2003 The American Academy of Otolaryngology – Head and Neck Surgery Foundation
Electrophysiologic Testing
• EMG - Electromyography (cont’d)
© 2003 The American Academy of Otolaryngology – Head and Neck Surgery Foundation
Facial Paralysis Secondary to 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
© 2003 The American Academy of Otolaryngology – Head and Neck Surgery Foundation
Acute Otitis Media
• Pathophysiology:
– 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%
© 2003 The American Academy of Otolaryngology – Head and Neck Surgery Foundation
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
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Acute Otitis Media
• Clinical reports: Hof
– 7 pts
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Acute Otitis Media
• Incidence in preantibiotic era:
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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:
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Recommendations
• Debated:
– A tube should be inserted
– Electrophysiological tests should be
used to determine if surgery is
necessary
– Decompression should accompany
mastoidectomy
– Steroids
© 2003 The American Academy of Otolaryngology – Head and Neck Surgery Foundation
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 ??
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Chronic Suppurative Otitis Media
– 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:
– 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:
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Recommendations
• CONSENSUS:
• DEBATED:
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Facial Nerve Trauma
General considerations
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Facial Nerve Trauma
Iatrogenic injury
• Anticipated or not
• Knowledge of anatomy
• Intraoperative monitoring
• Local anesthetic effects
• Early exploration
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Facial Nerve Trauma
Diagnosis
• Mechanism of injury
• 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
© 2003 The American Academy of Otolaryngology – Head and Neck Surgery Foundation
Facial Nerve Trauma
Temporal Bone Fracture
• High-resolution CT
• Mechanisms of injury
• Stretch (50%)
• Transection (30%)
• Compression (20%)
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Temporal Bone Fracture
Transverse
Longitutdinal
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Longitudinal Fractures
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Transverse Fractures
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Facial Nerve Trauma
Electrophysiologic Testing
• Paralysis only
• After 3 days
• ENOG appears most accurate initially
© 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
© 2003 The American Academy of Otolaryngology – Head and Neck Surgery Foundation
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
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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)
• Cable grafting
• Crossover procedures
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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
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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
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Eyebrow
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Midface
• Cosmesis
• Breathing
• Static
• Dynamic
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Dynamic Midface
Rehabilitation
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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
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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