!

OTOLARYNGOLOGY)–)HEAD)AND)NECK)SURGERY)
Lectured!by:!Nathaniel!W.!Yang,!MD,!FPSOHNS!
!!!!!!!!!!December!15,!2015
FEU2NRMF!Institute!of!Medicine!
!
FACIAL)NERVE
) !
Otolaryngologist) ! Courses! through! the! posterior! fossa,! temporal! bone,! and!
- Most! qualified! to! diagnose! and! manage! paralysis! of! facial! parotid! gland,! which! renders! the! nerve! vulnerable! to! many!
nerve! because! of! his/her! background! in! head! and! neck! neoplastic,!traumatic,!and!infectious!events!
anatomy!and!pathology!and!skill!in!temporal!bone!surgery! )
! SEGMENTS!
All!clinicians!should!be!able!to!recognize!a!peripheral!paralysis! 1. Intracranial!
and!initiate!proper!evaluation.! - Frontal!branch!component!of!the!facial!nucleus!
) !
ANATOMY)AND)PHYSIOLOGY) 2. Intrameatal!
) - Accompanied!by!CN!VIII,!travels!thru!the!internal!auditory!
FACIAL)NERVE) canal!to!the!fundus!
! Provides!afferent!and!efferent!innervation!to!structures!derived! - Narrowest!point!in!the!bony!fallopian!canal!(facial!canal)!
nd
from!the!2 !branchial!arch! - Site! where! the! nerve! is! most! likely! to! become! entrapped!
! Special)Visceral)Efferent)Fibers) due!to!inflammatory!swelling!
• Most!fibers! !
• Supply!nerve!inputs!to!! 3. Labyrinthine!
- Striated!muscles!of!facial!expression! - Segment!after!running!a!short!distance!anteriorly!in!which!
st
- Stapedius!muscle! the! facial! nerve! gives! off! the! greater! petrosal! nerve! (1 !
- Stylohyoid!muscle! branch!of!the!facial!nerve)!with!its!secretory!fibers!to!the!
- Posterior!belly!of!the!digastric!muscle! lacrimal!glands!and!the!nasal!mucosal!glands!
! General)Visceral)Efferent)Fibers! !
• Form! the! nervus! intermedius,! which! innervates! the! 4. Tympanic!
following! - Runs! horizontally! through! the! middle! ear,! passing! above!
- Lacrimal!gland!and!seromucinous!glands!of!the!nasal! the! stapes,! to! the! aditus! ad! antrum! near! the! lateral!
cavity! via! the! greater! superficial! petrosal! nerve! and! semicircular!canal!
pterygopalatine!ganglion!! !
- Submandibular! and! sublingual! glands! via! the! chorda! 5. Mastoid!
tympany!and!the!submandibular!ganglion! - Courses! through! the! mastoid! and! leaves! its! bony! canal! at!
! Special)Sensory)Fibers! the!stylomastoid!foramen!
• For!taste! - Gives!off!the!chorda!tympani,!which! contains!the!sensory!
• Innervate! the! anterior! 2/3! of! the! tongue! via! the! chorda! gustatory!fibers!
tympani,!and!the!tonsillar!fossae!and!palate!via!the!greater! !
superficial!petrosal!nerve! 6. Extracranial/)Extratemporal)Segment!
• Geniculate)Ganglion! - Part!after!emerging!the!stylomastoid!foramen!
- Contains!the!cell!bodies!of!these!sensory!neurons! - Enters! the! parotid! gland! where! it! branches! into! the! pes!
! Somatic)Sensory)Fibers! anserinus!
- Provide! sensation! to! touch! of! the! external! auditory! canal! - Branches! into! the! frontal,! ophthalmic! and! oral! branches!
and! conchal! skin! of! the! auricle,! and! proprioceptive! which!supplies!the!muscles!for!facial!expression!
information!from!the!facial!muscles! !
! Visceral)Afferent)Fibers! FUNCTIONS)
- Supply!the!mucosa!of!the!nose,!pharynx,!and!palate! ! Innervates!muscle!of!facial!expression!
! Origins!of!motor,!preganglionic,!and!sensory!modalities! ! Taste!to!anterior!2/3!of!ipsilateral!tongue!–!via!chorda!tympani!
- Motor!nucleus!(motor)! ! Lacrimation!2!most!important!(doctor’s!point!of!view)!
- Superior!salivatory!nucleus!(preganglionic)! ! Salivation!–!Greater!superficial!petrosal!nerve!
- Nucleus!of!the!solitary!tract!(sensory)! ! Impedance!regulation!of!middle!ear!–!Stapedius!Nerve!
! Fallopian)Canal! ! Sensation!of!pain,!touch,!taste!and!temperature!
- Bony!Canal!where!FN!traverses!the!temporal!bone!! !
- Begins! at! the! fundus! of! the! internal! auditory! canal! and! !
terminates!at!the!stylomastoid!foramen! !
! Lacks! a! fibrous! sheath! or! endoneurium! within! the! internal! !
auditory!canal!and!is!surrounded!by!a!thin!layer!of!arachnoid! !
! !

Joan!Marie!Sales! 1!
MD!2017!23D! !
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! Afferent!fibers!
- Convey! taste! from! anterior! 2/3! of! tongue! to! nucleus!
tractus! solitaries! via! lingual! nerve,! chorda! tympani,! and!
nervus!intermedius!
- Mediate!sensation!from!posterior!external!auditory!canal,!
concha,!ear!lobe!and!deep!parts!of!face!
!
I. NERVE)INJURY)
! Histologic! and! biochemical! changes! occur! on! the! nerve! cell!
when! a! nerve! is! injured! by! any! means,! trauma! or! systemic!
changes)
)
Categories)or)Degrees)of)Damage)
(Sunderland!Classification)!
O
1 )Damage)) Reversible!conduction!block)
(Neuropraxia))) )
O)
2 Damage)! Loss! of! structural! continuity! of! axon! with! intact!
(Axonotmesis)) endoneurial!sheath)
O)
! 3 Damage)! Loss! of! continuity! of! axons! and! endoneurial!
(ppt!from!OHNS!Department)!
!
(Neurotmesis)) sheaths)
O
! 4 )Damage) Loss!of!continuity!of!axons,!sheaths,!funiculus)
O
5 )Damage) Complete!loss!of!nerve!continuity)
!
II. DEGENERATION)
! Interruption! of! the! continuity! of! the! axon! separates! the! distal!
axon!from!its!metabolic!source,!the!neuron!or!cell!body)
! Wallerian! degeneration! of! the! distal! axon! and! myelin! sheath!
begins!within!24!hours)
! Macrophages!phagocytize!degraded!myelin!and!axons)
)
III. REGENERATION)
! Neuron! metabolism! leads! to! increases! in! mRNA,! enzymes! and!
structural!proteins)
! Axonal! stumps! swell! with! axoplasm! and! proliferation! of!
neurofilaments)
! Conditions!at!the!site!of!injury!govern!the!fate!and!organization!
of!the!sprouts)
! Simple!misdirection)
- Entry!of!one!axon!into!a!tubule!destined!for!a!muscle!other!
than!the!one!previously!innervated)
)
!
(http://www.slideshare.net/vicky14381/facialFnerves)! PHYSICAL)EXAMINATION)
! Facial! weakness! can! be! extremely! subtle,! apparent! only! to! a!
PATHOPHYSIOLOGY)OF)THE)FACIAL)NERVE)INJURY) trained!examiner!(and!to!the!patient))
! The!facial!nerve!has!a!mixed!motor2sensory!nerve!innervation! ! Mild! unilateral! facial! weakness! can! sometimes! be! more! easily!
! Efferent!fibers!from!the!motor!nucleus!innervate!muscles!of:!!!!! detected!than!a!normal!contralateral!side!by!having!the!patient!
- Facial!expression! perform!a!nominal!than!maximal!volitional!movements)
- Post2auricular! ! Rapid! repetitive! blinking! can! unmask! mild! facial! weakness,!
- Stylohyoid,!posterior!digastric! which!manifests!as!slowed!or!reduced!blink!frequency!than!the!
- Stapedius!muscle! normal!side)
! Superior)Salivary)Nucleus! ! Total!or!Near2total!Facial!Paralysis!(obvious!diagnosis))
- Projects!efferent!(parasympathetic!preganglionic)!fibers!to! - Can!be!devastating!to!the!patient!on!functional,!social,!and!
sphenopalatine! ganglion! where! postganglionic! fibers! then! psychologic!levels)
innervate!lacrimal!glands!and!mucinous!glands!of!the!nose! ! HouseWBrackmann)System)
! Another! set! of! parasympathetic! fibers! synapse! at! the! - Most!widely!used)
submandibular!ganglion! - Endorsed! by! the! American! Academy! of! Otolaryngology2
! Postganglionic!fibers!connect!the!submandibular!and!sublingual! Head!&!Neck!Surgery)
glands! - Grade! I! is! normal! function,! Grade! VI! is! complete! absence!
! and!Grades!II2V!are!intermediate)
! )

Joan!Marie!Sales! 2!
MD!2017!23D! !
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Grade) Description) Characteristics) STAPEDIUS)REFLEX)
I) Normal! Normal!facial!function!in!all!areas! ! The!nerve!to!the!stapedius!muscle!branches!off!the!facial!trunk!
nd
II) Mild! Gross) past!the!2 !genu!in!the!vertical!(mastoid)!part!of!the!nerve)
Dysfunction! - Light! weakness! notiveable! on! close! ! Acoustic)Reflex)Test)
inspection) - Used!to!assess!the!afferent!(auditory)!limb!of!the!reflex!in!
- May!have!very!slight!synkinesis) patients!with!hearing!loss)
At)rest!–!Normal!symmetry!and!tone! - In! cases! of! facial! paralysis,! the! same! test! is! used! to! asses!
Motion) the!efferent!(facial!motor)!limb)
- Complete! closure! of! the! eyes! with! • Abnormal) –) Absent! reflex! or! reflex! <1.2! the! amplitude! of!
minimum!effort) the!contralateral!side)
- Mouth!with!slight!asymmetry) ! Elicited!by!ipsilateral!or!contralateral!acoustic!stimulation,!or!in!
III) Moderate! Gross) cases!of!bilateral!severe!HL,!by!tactile!or!electrical!stimulation)
Dysfunction! - Obvious! but! no! disfiguring! difference! ! Absent!in!69%!of!Bell’s!palsy!cases!(in!84%!when!the!paralysis!is!
between!2!sides! complete)!at!the!time!of!presentation)
- Noticeable! but! no! severe! synkinesis,! ! Recovers! at! about! the! same! time! as! for! clinically! observed!
contracture!or!hemifacial!spasm! movements)
At)rest)–!Normal!symmetry!and!tone) ! Limited!prognostic!value)
Motion) )
- Slight! to! moderate! movement! of! the! TASTE)
forehead) ! Chorda!tympani!carries!fibers!providing!taste!from!the!anterior!
- Complete! closure! of! the! eyes! with! 2/3!of!the!tongue)
effort) ! Psychosocial!Assessment)
- Mouth!slightly!weak!with!max.!effort) - Performed! with! natural! stimuli,! such! as! filter! paper! disks!
impregnated!with!aqueous!solutions!of!salt,!sugar,!citrate!
IV) Moderately2 Gross)
Severe! - Obvious! weakness! or! disfiguring! or!quinine!or!with!electrical!stimulation!of!the!tongue)
! Electrogustometry)
Dysfunction! asymmetry)
- Electrical!stimulation!of!the!tongue)
At)rest)–!Normal!symmetry!and!tone)
- Has!the!advantages!of!speed!and!ease!of!quantification)
Motion!
)
- None!(forehead)!
- Incomplete!closure!of!the!eyes! SALIVARY)FLOW)TEST)
! Requires! cannulation! of! the! submandibular! ducts! and!
- Mouth!asymmetric!with!max.!effort!
comparison!of!stimulated!flow!rates!on!the!2!sides)
V) Severe! Gross!–!Only!barely!perceptible!motion!
! Reduced!Submandibular!Flow)
Dysfunction! At)rest!–!Asymmetry!
- Lesion! at! or! proximal! to! the! point! at! which! the! chorda!
Motion)
tympani!nerve!leaves!the!facial!trunk)
- None!(forehead))
- Variable! and! may! be! anywhere! in! the! vertical! (mastoid)!
- Incomplete!closure!of!the!eyes)
portion!of!the!nerve)
- Mouth!with!slight!movement)
! Time2consuming!which!is!why!it!is!not!widely!used)
VI) Total! No!movement! )
Paralysis! SALIVARY)pH)
) ! A!report!showed!that!a!submandibular!salivary!pH!of!6.1!or!less!
TOPOGNOSTIC/DIAGNOSTIC)TESTS) predicts!incomplete!recovery!in!cases!of!Bell’s!palsy!
! Intended!to!reveal!the!site!of!lesion!by!use!of!a!simple!principle;! ! Only! the! duct! on! the! affected! side! needs! to! be! cannulated!
Includes!the!following:) because!all!of!the!control!sides!had!pH!of!6.4!or!more!
) ! 91%!overall!accuracy!of!prediction!
LACRIMAL)FUNCTION) ! Limited!reported!experience!
! SCHIRMER’S)TEST) ! Unknown!whether!it!gives!an!earlier!prognosis!than!other!tests!
- Test!in!which!the!physician!places!a!folded!strip!of!sterile! !
filter! paper! into! the! conjunctival! fornix! of! each! eye! and! NERVE)EXCITABILITY)TEST)
compares!the!rate!of!tear!production!of!the!2!sides) ! Stimulating!electrode!(square!pulse!of!0.3!msec!duration)!over!
! Normally,! the! portion! of! the! filter! paper! in! contact! with! the! the! terminal! ramifications! of! the! facial! nerve! →! one! increases!
conjunctiva! acts! as! an! irritant,! stimulating! an! increase! flow! of! the! current! (milliamperes)! until! movement! in! the! appropriate!
tears,! which! are! then! wicked! along! the! filter! paper! strip! by! muscle!group!is!just!visible)
capillary!action) ! Normal! values! (unaffected! side! of! face)! are! compared! to! the!
! The! length! of! the! wetted! portion! of! the! strip! after! a! fixed! side!of!paralysis)
interval!(usually!5!minutes)!is!measured!and!is!proportional!to! - 3.5mamp!or!more!difference!=!unfavorable!prognosis)
the!volume!of!tears!produced) )
! (+)!If!affected!side!shows!<1/2!the!amount!of!lacrimation!seen! )
on!the!healthy!side) )
) )
)
Joan!Marie!Sales! 3!
MD!2017!23D! !
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ELECTRONEUROGRAPHY)(Evoked)Electromyography)) IDIOPATHIC)FACIAL)PARALYSIS)(BELL’S)PALSY))
! Square! wave! impulses! of! 0.2! msec! duration! and! 502100! volt! ! MC! type! of! facial! nerve! paralysis! followed! by! traumatic! and!
amplitude! with! a! frequency! of! 1/sec! are! delivered! with! a! inflammatory!otogenic!forms)
bipolar! electrode! in! front! of! the! tragus! while! a! second! bipolar! ! Synonymous! to! cryptogenic,! rheumatic,! or! ischemic! facial!
electrode! captures! the! compound! action! potentials! of! paralysis)
underlying!facial!muscles!in!the!nasolabial!fold! ! Unilateral,! peripheral! paralysis! of! acute! onset! with! no! evident!
! Differences! in! amplitude! of! the! potentials! of! the! intact! and! cause)
involved! side! of! the! face! correlates! with! the! percentage! of! ! Unclear! pathogenesis,! however! there! are! several! theories!
degenerated!motor!fibers!(denervation)! which! include! infection! &! inflammation,! vascular! causes! and!
! Facial! nerves! subjected! to! traumatic! injuries! of! a! magnitude! ischemia)
requiring! surgical! repair! undergo! 90%! degeneration! within! 6! ! PostWauricular)Pain)
days!of!injury! - MC!early!symptom,!followed!by!unilateral!peripheral!facial!
! Bell’s!Palsy! paresis/paralysis)
- Poor!prognosis!if!patients!reach!95%!or!more!degeneration! ! Symptoms! develop! usually! within! 2! 25! days! and! have! no!
with!14!days!of!onset!of!the!palsy! systemic!manifestations)
) ! Clinical)Features:)
AUDIOMETRY) - Hyperacusis)
! Patients! with! facial! nerve! paralysis! should! undergo! complete! - Dysgeusia)
audiogram! including! air! and! bone! conduction,! and! - Decreased!lacrimation)
tympanometry) ! Diagnosis)
! Also!part!of!topographic!testing!is!stapedial!reflex) - Based! on! clinical! course! and! absence! of! any! discernible!
! Speech! Discrimination,! Tone! Decay! Test,! Auditory! evoked! cause!of!the!paralysis)
Potentials) ! URTI!may!precede!the!onset!of!paralysis)
- Used! to! screen! for! retrocochlear! lesions! (tumors! of! the! ! Majority!recover!spontaneously;!Good!prognosis)
cerebellopontine!angle)) ! Does!not!recur)
) ! Treatment)
)IMAGING)STUDIES) - Corticosteroids! (sometimes! combined! with! antivirals),!
! CT!with!or!without!contrast!(radiopaque!and!air)) though!efficacy!has!not!been!confirmed)
- Preferred! for! lesions! of! internal! auditory! canal! (IAC),! - Important! to! protect! the! eyes! by! prescribing! moisturizing!
posterior!fossa,!and!brain!stem.) eye!drops)
! High!resolution!scans!for!base!of!skull!lesions) )
! MRI!) CONGENITAL)LESIONS)
- Best! for! soft! tissue! assessment! and! tumors! of! the! facial! ! Uncommon)
nerve) ! MÖBIUS)SYNDROME)
) - MCC!which!results!from!an!underdeveloped!CN!VI!&!VII)
CAUSES)OF)FACIAL)NERVE)PARALYSIS! - Rare!&!has!an!unknown!cause)
! ! Patients!present!with!bilateral!facial!nerve!paralysis)
! Some!facial!nerve!paralysis!occurs!during!a!traumatic!childbirth!
Differential)Diagnoses)
trauma)
Idiopathic) Bell’s!palsy! ! Use!of!obstetrical!forceps!can!cause!temporal!bone!fracture)
Melkerson2Rosenthal!syndrome! ! It!is!important!to!identify!cause!of!paralysis!in!neonates)
Trauma) Temporal!Bone!Fractures! ! If! injury! is! secondary! to! birth! trauma,! electrical! stimulation! is!
Surgical!Trauma! possible!in!several!days)
Obstetric!Trauma! )
Infections) Otitis!Media! INFECTIONS)
Herpes!Zoster!Oticus! ! Can! occur! anywhere! along! the! path! of! the! facial! nerve! and!
Lyme!Disease! result!to!paralysis)
Tuberculosis! ! Reactivation! of! herpes! zoster! or! Ramsay! Hunt! syndrome! is!
Congenital) Möbius!Syndrome! associated!with!facial!nerve!paralysis)
Inflammation) Cholesteatoma! • Management!–!Antiviral!drugs!or!oral!corticosteroids)
Guillain2Barre!Syndrome! ! Otitis! media! can! spread! to! the! facial! nerve! compressing! the!
Tumors/Neoplasms) Facial!Neuroma! nerve!in!its!canal)
Malignant!Tumors!of!the!temporal!bone! • Cholesteatoma!may!be!present)
Meningioma! • Treatment)
Metabolic) ! - Antibiotics)
! - Myringotomy!(incision!in!the!tympanic!membrane)!to!
! decompress!the!middle!ear!and!sometime!surgery)
! ! Lyme)disease)
! - Tick2borne! illness! cause! by! a! spirochete! Borrelia(
! burgdorferi!can!also!cause!facial!nerve!paralysis)

Joan!Marie!Sales! 4!
MD!2017!23D! !
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) )
TRAUMA) )
! Common!–!Trauma!to!the!temporal!bone) )
! Possibility! of! facial! nerve! paralysis! depends! on! the! location! of! )
the!trauma) )
! Transverse)fractures)in)the)temporal)bone) )
- Injure!the!facial!nerve!more!frequently) )
! Management) )
- (Mild!injury):!same!with!Bell’s!palsy!) )
- Surgical!may!be!beneficial) )
! Paralysis!can!follow!immediately!after!the!trauma!secondary!to! )
direct!damage!to!the!nerve) )
) )
TUMORS) )
! Any! tumor! that! compresses! the! facial! nerve! along! its! pathway! )
can!cause!paralysis) )
! MC! neoplasm! in! the! cerebellopontine! angle! such! as! Acoustic) )
Neuroma) )
! Other!tumors!include) )
- Tumors!in!the!middle!ear!(glomus!jugulars)) )
- Hemangiomas) )
- Parotid!gland!tumors) )
- Metastases!of!other!tumors) )
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) Sources:!
) ! Otolaryngology!–!Head!and!Neck!Surgery!
) A!Textbook!for!Medical!Students!2015!(pages!47F55)!
) ! Powerpoint!of!Dizziness!and!Vertigo!
) ! Lecture/!Recording!!
) !
) !
) THANK)YOU)KATE)TAN!))
) ")<3)
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Joan!Marie!Sales! 5!
MD!2017!23D! !
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