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    MCQs on facial nerve palsy in plastic and reconstructive surgery

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    MCQs on facial nerve palsy in plastic and reconstructive surgery

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    © All Rights Reserved
    Download as PDF or read online from Scribd
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    25 views14 pages

    BR Facial 2 Chapters

    Uploaded by

    bran makmorn
    MCQs on facial nerve palsy in plastic and reconstructive surgery

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
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    of 14
    | _ Facial Nerve Anatomy and Paralysis Douglas M. Sidle, MD, and Rakesh K. Chandra, MD EMBRYOLOGY AND ANATOMY Whar branchial arch does the faeial REEVE innervate? ‘The second (hyoid) arch, What cartilage is associated with the second branchial arch? Reichert’ cartilage, (OR mat GHEE doce the facil neve innervate? a Q Through which foramen docs the facial nerve exit the skull? Siylomasoid What term is used to describe the network of anastomoses of the extratemporal facial nerve? “The eS ARGEHAUE) and arborization What docs pes anserinus mean? The foot of a goose What are the three majot landmarks used ( identify the facial nervelas it exits the stylomastoid foramen? 1. The tympanomastoid fissure: 6 to 8 mm inferior to the drop-off ofthe fissure 2. ‘The tragal pointer: I'em antetiorand 1 em inferior to the point. 3. Retrograde dissection of the posterior belly ofthe digastric musele ‘The facial nerve is almost invariably found at a point where the tip of the mastoid, cartilaginous process of the auditory canal, and superior border of the posterior belly of che digastrics muscle meet. 399 400 Plastic & Reconstructive Surgery Board Review 6 © @ Where does che pogeerigg bellisatshie digastric muscle insert on the skull? ‘Themedialaspecr of she masoid)portioniofthetemparal Bons, ‘What are the extratemporal branches of the facial nerve? ‘Temporal, Zygomatic, Buccal, Marginal Mandibular, Cervical (Mnemonic: To Zanzibar By Motor Car). Some patients have a branch co the pastauricular MUSCAT but this is considered vestigial, ‘What functional fiber types comprise the facial nerve? |SVA: fa fom AnFeiOF BHO tongue va GORA WmpaniNO TE HACTENalaTI (GMB motor branches to muscles AGELESS TRE SPEED) and GPGLPERAT che motor nucleus in ‘the pons. (GSA. sensation from she eanehalbaiiand paf¥oF he Exel RORY canal) GVE: parasympathetic stimulation of lacrimal, submandibulaysublingal land, and minor salivary glands (all glands in the head bue the parovid) ‘What is the blood supply to the facial nerve? Stylomastoid areery branch of posterior auricular artery. Greater superficial petrosal artery from the middle meningeal arvery. ‘5m pea ‘spa-mma What are the 18 muscles of facial expression? Froncalis, o:bicularis oculi, cortugator supercli, procerus, 2ygomaticus major and minor, levator labii superiors, levator abii superiorisalaeque nasi, levator anguli oris, naslis, buccinator, depressor septi nasi, orbiculars ovis, depressor anguli ors, depressor labii inferior, mentalis,risorius, and plarysma. Besides the muscles of facial expression, what muscles are innervated by the facial nerve Sapodius, splohyod, and iepeRor Hh OF NE UEC) What is SMAS? Superficial Musculo Aponeurotc System, Is an NEA fibrous tse immediatly below the skin and suboutancous fat of che faceinto whi ee facial mules inser, ci eoniguous wih he lagna ino and ‘he superficial semporl cia andthe gales supetony, Where does the facial nerve course in the parotid region? “Through the substance of the gland Where do the nerve branches exit the sya cao coune mpi fascia to course superficially? Branches ext a the anterior limit ofthe parotid gland, continuing deep to the SMAS. ‘What is the most commonly permanently injured branch of the facial nerve during rhytidectomy? The temporal branch at the zygomatic arch. Where does the temporal branch cross the zygomatic arch? Halfway between the lateral eanchus and the root of the auricular helix. Qo o CHAPTER 47 Facial Nerve Anatomy and Paralysis 401 What is Pings Hine Irie theoretical line teflectng (HEGBSRE he emipatal branch of he fal nee, Is 0.5 em below che eagus toa poine 1.5 em lateral the superior orbital rims, wa from a point Between which fascial layers does the frontal branch of the nerve course as it crosses the zygomatic arch? ‘The branch courses deep to the SMAS and immediately superficial co the superficial laver of deep temporal fascia. A.stroke patient may maintain fanction of the frontalis muscle even though all of the other facial muscle on the ipsilateral side are paralyzed. Why? Because the netve fibers that project to the parc of the facial nucleus in the pons that innervate the forchead project bilaterally, hut chose that project to the patt of the nucleus that innervates the remaining facial muscles project only ccontralaterally. it crosses the mandible? ‘What fascial layer does the marginal mandibular nezes lay deep to ‘The netve les immediately beneath the superficial layer of che deep cervical fascia ‘What branch of the facial nerve innervates the buccinator muscle? Buccal branch of the facial nerve ‘Ac what sit isthe primary action of botulinum toxin? FACIAL NERVE PATHOLOGY Why does a lesion proximal to the motor nucleus of VII produce paralysis of only che lower face, whereas a Icsion below the motor nucleus produce complete facial paralysis? ‘The lower face receives inpuc from motor act fibers that have crossed only once in the pons, while (hg_uppentiee -teceives input from crossed and uncrossed fibers from the motor tract. What isthe House-Brackanan grading eystem? ‘A standard system so evalaterthe degree of recovery Of facial nerve function from 1 (normal) co 6 (complese atalysis) What is the most common form of liopathic facial paralysis? Bells palsy, 15 t0 40 per 100,000. What percentage of Bell palsy is recurrent? 1096 to 14%. What is Bell palsy? diagnosis oF exeusion, iis idiopathic facial paralysis wich siden onsct and spontaneous elution 402 Plastic & Reconstructive Surgery Board Review © © O What percentage of Bell palsy presents with gomplete paralysis? 6%. Over what time period do the majority of Bel pases resolve? 40 6 months, O What proportion of Bell palsy presenting with House-Brackmann grade 6 fesolve completely? (7098, More shan 909% presen With inoRplEe paralysis resolve O_ What other symptoms do patients with Bel palsy often present with? Vial prodrome, numbness ofthe eat, fice, neck, dyageusi,AYpeReWsis, and dceresed ering)” O Ifa Bell palsy patient is seen in the first few days, what medications can be prescribed? A prednisolone taper has been shown to improve outcomes. Less evidence supports antivirals, such as acyclovir, they are commonly prescribed in conjunction with the prednisolone taper. What is Bell phenomenon? Upwardoutward roration’of the evel with attempted eyet closure? This isan unconscious movement co protect che cornea. It ia positive sign, What percentage of patients with Lyme disease develop ficial paralysis? (10%, Paralysis may be bilacral All resolve with appropriate Lyme disease treatment What is the most common cause of bilateral facial paralysis Guillain-Barre syndrome, O What ie Metkersson-Rosenthal syndrome? ‘Syndrome of unknown etiology characterized by recurrent facial nerve paralysis, woody facial edema, and.a deeply Fsured tongue What is neuropraxia? (Compson nerve revuing in deteased ansmish wicbouTERORTORSORS O Whasisaonoemesie Distuption of xs sesuling in Wallesian degeneration distal wo dhe lesion wich presgpaion ofthe acl sheaths ‘Complete sscovery expected). What is neurotmesis? Disruption of axons and support cells leading to Wallerian degeneration and uncsgginseturn co funcsion, —_— OO What is syphinesis? Synkiness is abnormal synchronization of movement, accurting with voluntary and reflex activity of muscles chat normally do not contract together. This phenomenon occurs rom ful ssmusination of regenerating nerve bets © © © CHAPTER 47. Facial Nerve Anatomy and Paralysis 403 ‘What is Bogorad syndrome? Nerves orginally destined for the submandibular gland innervate the lacimal gland leading (SHEER (gUFAION. Also known as roe aT Where is the site of lesion leading to “crocodile tears"? ‘ee vet na ms satatsmna pila patio egos nama Facial nerve at that point. What is Frey syndrome? Gustatory sweating secondary to autonomic branches to the parotid cross innervating check sweat glands and blood vessels ‘What are the most common causes of facial paralysis in children? Bell palsy (37%). Trauma (20%), ‘What is the most common cause of facial paralysis in neonates Birth trauma, What are the most common causes of facial nerve disorders in adults? Bell palsy (5196). Tiauma (2396). Tamor (5%). ‘The facial nerve should be electrically monitored when dissecting and extirpating which branchial cleft abnormali © © FACIAL NERVE EVALUATION AND REHABILITATION © © © ‘What is an EMG? EMG stands for Eleet@MyoGHaphy, Ic is tool to measureWOlURtakY HEWEand muscle function. Probes ate placed into the test muscles (i facial muscles) and the patient Wolitionally ries to contract those muscles. What is the significance of fibrillation potentials on EMG? Fibrillation potencials are spontancous musele action potentials that occur 2 to 3 weeks after injury and signify 1e muscle, This shows paor prognosis) denervation of ¢ What is the significance of polyphasic potentials on EMG? Polyphasic potentials ae recorded from nearby nerve fibers and signify reinnervation of the musele. They are the catliest sigh of nerve regeneration, This reveals good prognosis) What is ENG (or EMG)? InjBleetroNeuroGraphy (or Evoked EleccroMyoGraphy), the nerve is electrically stimulated by a probe. This measures and compares the amplitude of summation potentials of the paralyzed face to che normal side. AOA Plastic & Reconstructive Surgery Board Review © © Whereis the likely site of a facial nerve lesion in a newborn baby with a normal examination, no evidence of birth trauma, and unilateral facial paralysis? normaliges. This is evaluated with aC sean of the head and temporal bones. Likewise, serial electrical cesting is performed. No activity on EMG and >90% reduction on ENoG (EEMG) suggest congenital cause, not birth trauma. © When should you consider surgical decompression of the facial nerve in a temporal bone fracture? immediatly fier the injury and serial ENoG shows progrsion to O When do you do decompress the nervelf there is Voluntary aetivity’ on EMG? the nerve because its continuity has been established. Likewise, if patient presents with head ‘trauma and the facial nerve is initially intact but progresses co complete facial paralysis over the next few hous, dlecompresion isnot indieated, The neve can be presumed as intact by snl observation of Function) What isthe primary concern when initially managing a patient with facial paralysis? Protection of thege rom ophthalmologic sequela including exposure keratitis, corneal let and potential Blindness, What nonsurgical treatments exist for eye protection in facial paralysis? Hidiating drops ointment, moisture chamber ld taping at night, external eyelid weights, and physical therapy (using surface electromyography or mirror feedback) O What surgical procedures are available for eye protection? Lateral canopy ling procedures, aerial whoring sezortaphy, an lid loading wit gold we placement, rarely medial canthoplasty. Owes an upper eyelid wight placed? 1c is placed Special to Use Upper sal plage and che leVATORApONeURGHs with che inferior edge a few millimeters above the ash line. Ie is generally placed centered over the junction of the central and medial one-third of the «eyelid, generally over the medial limbus What is the next alternative for eyelid weight placement in patents with contact allergy to gold? Platinum, O Whatdynimie reanimation procedures may be accomplished? ‘Temporalis ransposition, free muscle ransfer with mictoncuronal, and microvascular anastomoses What is astatiesting procedure? Suspension ofthe flected musculature with Gore-Tex asia laavorallograltdermalissue, © © © CHAPTER 47. Facial Nerve Anatomy and Paralysis 405 What procedures are used to restore neural input to the facial muscles? Primary sepair of the nerve or neurorthaphy, cable grafting, cross-face grafting, MUI crossover, KI-VIL ‘rossover, jump grafts, ‘What proximal nerve can be used to provide a éable graft of 10 em or less? Great auricular nerve, What nerve is used for cable grafis requiring 210 em? ‘Sural nerve (up co!35iem). What is the technique of neurorrhaphy? Interrupted sucures of 920%R¥168 placed in the @ineUHURY In the case of a severed nerve, what type of nerve repair generally produces the best outcomes? Generally, a primary repair of the nerve will produce’ better outeoméstthan a repair with an interposition, or jump gral ‘When evaluating a deep facial laceration, what landmark can be used to help determine if« primary nerve repair is warranted? -Atraumatically lacerated facial nerve is generally not repaired if itis com distal to a line drawn vertically from the ‘eral eanthus, This isin pare due to the size of the distal nerve stumps and in part due to the arborization of distal nerve endings at that poins. How loog should « surgeon counsel patients than a grafted nerve will take to achieve its bes outcome? Becwcen3 months and 2 years, In what situation should a XIL-VII crossover be considered to reanimate a paralyzed face that is caused by a facial nerve disruption? When the proximal facial nerve stump is not available and the peripheral system is viable (less than 2 years from the time of the trauma). What isa XILGVIlefossover wihijump graf “The hypoglowslinetvelisvolated and one-third to half of the nerve is incised. (A(gReaW autictla nervelgraft is sucured to the protimal cu segment of the hypoglossal nerve and is anastomosed co the eutfasal neve. This procedure shows comparable outcomes to the dir @EXILEMIfossover, provided itis performed in the fist 30 days following neve injury. ‘What unique morbidity can result from a XII-VII crossover or XII-VII jump graft Distuption of the hypoglossal nerve can result in difficulties with mastication and articulation. To mixigace this complication, only one-third of the hypoglossal nerve is incised and a jump graft ean be used. cedure? 406 Plastic & Reconstructive Surgery Board Review © © O What is cross-facial nerve grafting? ‘Anerve graft is anastamosed with consaattal al branches and canneed othe opposite side of the face where ic isanastmosed with che et branche of the paralyzed side, This echnique as primary therapy as largely fallen ‘out of favor and is generally reserved fr powering a fee muscle graf. How long after paralysis may reinnervation techniques prove use ‘Withiti2ivears of the onset of paralysis; after this point progressive muscle atrophy precludes the use of reinnervation techniques, O _Deseribe the two-stage technique of microvascular free tissue transfer. Sural nerve geafe and is tagged. Approximately 9 co 12 months later, ree tissue ransfer of gracilis muscle and neurovascular pedicle is performed, and the cross-facial nerve is anastamosed with the pedicle. tunneled from an anastomosis with contralateral buccal branches o the involved side of the face O What orientation is the sual nerve grafted? Reverse of rotated. However newest evidence suggests directionality ofthe graft does not impact res O Describe she single-stage technique Free muscle transfer is performed with exoss-facial tunneling of the nerve pedicle to che conttalaceral buccal nerve branches. What is the advantage of singlestage repair? The axons need only traverse a single anastomotic line to reach the destination muscle. Less morbidity and quicker recovery is thus hypothesized, CO What are common muscles used in free tissue transfer facial reanimation procedures? Gaacilis pecorlie minor and serratus ancrion What dynamic reanimation technique can be used to reanimate the paralyzed face in onesrtageand provide immediate results © © REFERENCES © © © Bley BJ. Head and Neck Surgery: Otolaryngology. 3d ed. Philadelphia, PA: Lippineote Williams & Wilkins; 2001 Gant BY, Rubinsein JT, Gidley P Woodworth GG. Surgical management of Bells paly: Laryngoscope. 1999; 109:1177-1188. Lee KJ. Euental Otolaryngology: Head and Neck Surgery 8th ed, New York: McGraw-Hill 2003, May M. The Facial Nero. let ed. New York: Thieme; 1986 sing les. Ann Orel Rhinol Laryngol. 1979; 88(5)585-589. Papel ID, Frode [L, Hole GR, etal. Facial Plate and Reconstructive Surgery. 2nd ed. New York: Thieme; 2002. Sllivan FM, Sean 1598-1607, ‘MeCabe BF Autoimmune ensorineural . Donnan PT; etl. Early weatment with prednisolone or acyclovir in Bells palsy. N Eng J Med. 2007:357(16): Facial Paralysis: Static and Dynamic Treatment Jon A. Mathy, MD What are the cosmetic goals of treating the paralyzed face? Restore stati and dynamic fail symmetry. What are the functional goals of treating the paralyzed upper face? Coreec visual obstruction and proteetthe eyefiom exposure Keratits ©. What ate the Functional goals of treating the paralyzed mig? “Maintain the nas airway. O What are the functional goals of treating the paralyzed lower face? Regain orl continence and (aiitate communication (eth and emotive) What are the most common surgical treatments for the paralyzed brow? LobROWF through dice forehead excision 2, open coronal browlift 3. endoscopic browlife What are the most common surgical treatments for the paralyzed upper evelid with lagophthalmos? (Weve insertion Gvcight or spring) 2. laeal tnsothaphy 3. fa slip can be elevated from its origin and rerouted around the lateral orbital rim tothe ‘medial canthal ligament) What are the most common surgical treatment for the paralyzed lower eylid with ectropion? 1 ling suspension 2. laeral canchoplasy 3. horizon id shoring 4 cailage gating 407 408 Plastic & Reconstructive Surgery Board Review © © What are the most common surgical treatments for the paralyzed inasalaperttine? 1. cemporalis wansfer (eg, McLaughlin temporal tanslet) 2, static ding suspension 3. alar base elevation What are the most common surgical treatments for the paralyzed upperlip? 1, sling suspension 2, static tebalancing (e,Lacliftadvancemens) pov cans (eg MeLatighlin eniporalie ase) 4, fice fanctional muscle transfer What are the most common surgical treatments for the paralyzed lower lip? 1, wedge excision 2 digas waster © What structure should be preserved during dict SrSv/ftERSUphIfSREMESA Eis’ (Tse sapacebial nerve for ean obese alpHERAWOR, hic run ut deep to che fomtalie muscle athe lower forehead O Is there a role for weakening or paralyzing a normal hemiforchead? Yes, particularly in younger patients. Improved upper facial symmetry and forehead tone may be obtained with botulinum toxin oF frontal branch resection on a normal hemibrow, at the variable expense of emotive upper facial expression, Conttaindicaced in older patients where paralysis of a lax forehead would result in excessive brow rosie © Upper eyelid treatments are aimed at balancing the unopposed action of which facial muscle? Levator palpebrae superiotis (cranial nerve III). O What are the most popular implant alloys for upper lid loading? (Gola plat, bod of which arc highly imimnoiner Pati laws for OW prOSLe Tap) How are lid weights sized? Preoperatively in an awake patient, (181X008) g seis ate Faped 6 the Upperlid, Thelightes deve capable of pulling down the upper eyelid over the cornea to the lower limbus should be used. Complerelidelosurelis wot necessary, with oversized implants risking visual obstruction, © CHAPTER 48 Facial Paralysis: and Dynamic Treatment 409 Where are weights placed in the upper lid? laseral to center will optimize mechanics and minimize visibility (see Figure 48-1) snd biased slightly Weighted implant ‘Tarsal plate Figure 48-1. Ticatment of upper ficial paralysis with an upper lid weigh illustration by Jonathan Heather, MBCHB). O What is th [An inferiorly based strip of temporalis muscle isclevated from its origin in the temporal fossa and elongated with a strip of temporal fascia. This is then rerouted subcutaneously around the lateral orbital rim, across the tarsal plate, and inserted ino the medial canchal cendan, With temporal contraction the upper lid is pulled down, Anatomically, what allows a emporals sip transferred (oa paralyzed upper lid to remain dynamic aftce transfer? ‘The temporalis is vascularized and innervated via i und inferior susfa How do you perform » lateral easorthaphy? "Mashing deepishelaized segments of lateral upper and lower lids are appossd and allowed to heal togsther, What isan advantage of the lateral tarsorshaphy for comeal protection? Reliable pationt-independent improvement in corneal protection, This may be particularly useful in mentally cbilitated or demented patients, in eases of involving an anesthetic cornea, of in cases with severe corneal exposue ‘Tnde-ofsinclade aera visual obstruction and new asthetie asymmesics, O Overtime, with decreased midfacial one and a paretc orbiculars oculi, a ower lid ectropion with scleral show can develop. How can this be treated? ‘Ste supporgof welowerI (eg tendon or tensor fascia late (TFL) LAS) AERA (cx, dermal pennant or tarsal sip) horizontal id shortening ( Kune Srymanowaki proesdue), and/or check elevation procedures O How does nasal airway obstruction develop? Collapse of the nasal aperture through external compression arising from a drooping midéace as well as loss of

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