SHANZ – ENT 1.

06 FACIAL NERVE AND TRAUMATIC FACIAL PARALYSIS

FACIAL NERVE TERMINAL BRANCHES

• Motor innervation to the face Branch Innervation
• Travels through temporal bone, middle ear and parotid gland Occipitofrontalis
• Greater superficial petrosal nerve: first branch (supplies lacrimal & nasal mucosal gland) corrugator
Temporal
• Supply anterior 2/3 of tongue & part of submandibular gland via Chorda tympani procerus
• Supplies stapes & stapedius ms. Of middle ear upper orbicularis oculi ms.
• Extracranial segment: stylomastoid foramen (supplies parotid gland) Zygomatic Lower orbicularis oculi ms.
Zygomaticus major & minor
INTERNAL AUDITORY CANAL COMPONENT: Levator anguli oris
Buccal
CN 7: Superoanterior Buccinagors
CN 8: Inferoanterior (coca cola) Upper orbicularis oculi ms.
Superior vestibular nerve: Superoposterior Lower orbicularis oculi ms.
Inferior vestibular nerve: Inferoposterior Marginal Depressor anguli oris
Bill’s bar/ vertical crest → Superior → anterior and posterior mandibular Depressor labii
Tranverse or falciform crest (Crista falciformis) → IAC → Superior and inferior halves Mentalis
Cervical Platysma ms.

ANATOMICAL SEGMENTS OF FACIAL NERVE

INTRACRANIAL INTRATEMPORAL EXTRATEMPORAL
• CN 7 exits brainstem at pontomedullary junction • Labyrinthine
• Rostro-lateral course: enter porus of IAC of temporal bone (15-17 mm) • Tympanic
• Mastoid

INTRATEMPORAL
INTRAMEATAL LABYRINTHINE MASTOID TYMPANIC
• 8-10 mm long • Shortest segment (4 mm) • Longest intratemporal segment (13mm) • 11 mm long
• narrowest diameter passing • From meatal foramen to • Give rise to chorda tympani • near lateral semicircular
thru meatal foramen geniculate ganglion o Sensory innervation to anterior 2/3 tongue canal
o nerve swelling site o GSPN (Greater Superficial • Give rise to stapedius muscle nerve • most commonly injured
(nerves entrapped due Petrosal nerve) o stimulated upon tympanometry at 90 dB segment during mastoid
to inflammatory ▪ secretory fibers to o protects inner ear from further damage from surgery
swelling) lacrimal & nasal high volume
• BELL’S palsy mucosal gl • Forms 2nd genu
• Exits at stylomastoid foramen

FUNCTIONAL COMPONENTS OF FACIAL NERVE

SVE GVE GSA VSA
Special Visceral Efferent General Visceral Efferent General Sensory Afferent Visceral Sensory Afferent
Brachial motor Parasympathetic Sensory Taste
• supplies muscle of facial expression • via GSPN + Zygomaticotemporal nerve • Posterior auricular nerve • Afferent gustatory
o Stapedius ms o lacrimal gland o auricular concha • anterior 2/3 of tongue
o Stylohyoid ms • via chorda tympani + nervus intermedius o post auricular skin o Chorda tympani:
o posterior digastric ms o submandibular & sublingual gl o EAC wall • hard & soft palate
o buccinator ms o TM part
• forehead (upper face)
o bilateral innervation from UMN
• lower face
o contralateral innervation
 SUNDERLAND NERVE INJURY CLASSIFICATION
CLASS I CLASS II CLASS III CLASS IV CLASS V CLASS VI
NEURAPRAXIA AXONOTMESIS NEUROTMESIS NEUROTMESIS NEUROTMESIS NEUROTMESIS
• Moderate pressure on nerve • Wallerian • Endoneurium disrupted • Perineural disruption • Complete nerve • Mixed injury
• Axonal disruption degeneration • Wallerian degeneration • Only epineurium resection • Involves
• Conduction block • axonal & myelin • Synkinesis intact • all not intact neuropraxia and
• Intact endoneurium, sheath disruption o Regenerating axons may enter wrong endoneurial tube • Less aberrant • almost no hope neurodegeneration
peineurium, epineurium • no injury to • Frey’s syndrome/gustatory syndrome generation than class III for regeneration
• no physical disruption of supporting structures o lacerating trauma: CN7 innervation can cause perspiration • Greater synkinesis • Risk of neuroma
axonal continuity • Intact endoneurium, o When you see food: you ‘ll also perspire • Incomplete motor formation
• BELL’S PALSY peineurium, • Bogorad syndrome/crocodile tears function
• Common finding: loss of epineurium o fake tears • Need surgery!
motor function • CT remains viable for o CN 7 branches to GSPN
• CT remains viable for axonal axonal regeneration o excessive lacrimation during eating
regeneration • Happens in: traumatic/iatrogenic CN 7 dissection/ malignancy
• short circuiting; miswiring of nerves after trauma
• blinking with lips and mouth movement

PATHOPHYSIOLOGY APPENDIX
• facial movement: <7000 motor fibers in sync for muscle contraction
• Main neurotransmitter acetylcholine
o Manufactured in nerve cell body (pons)
o transported along nerve to MEP (motor end plate)
• CN 7: 1 motor unit @ CNS
• Motor cell axon (covered by schwann cells)
o neural tubule for non-myelinated nerves
o insulation myelin for myelinated nerves
• Nodes of ranvier: junction b/w schwann cells
• Rate of axoplasmic metab & movement: 1mm/day
o basis for axon regeneration

DIAGNOSTIC TESTING
AUDIOLOGIC: TEAR TEST/ SALIVATION NERVE FUNCTION TEST
TYMPANOMETRY SCHIMER’S TEST
• Stapedial reflex test • output of lacrimal gland • Cannulation of submandibular ducts (Wharton) • EMG
o from mastoid segment • 5 cm litmus paper @ lower lid into conjunctival sacs • uses No.50 polyethylene • ENOG
o (-) reflex: lesion proximal to mastoid segment • 3 min: difference > 25% = potential CN 7 damage • cotton saturated w/ lemon juice @ mouth • MAXIMAL STIMULATION TEST
Indicate definite nerve damage • Likely damaged: labyrinthine segment • compare volume: <25% = abnormal
• not done anymore, invasive
TELL IF INJURY IS PROXIMAL (GSPN involvement) /DISTAL
 NERVE FUNCTION TEST
EMG ENOG MST
• done 21 days after acute paralysis • Stimulate 1 point; measure EMG at a more distal point; compare 2 sides after 10 days • nerve stimulation
• electrode into muscles • >90% degeneration = reduced recovery chance • muscle twitching
• Rule out myopathic VS neuropathic • most accurate test • Discomfort current
• demonstrate functional motor units • electrode (stimulate CN 7 w/ transcutaneous impulse) • not done anymore
• voluntary AP: partial continuity of nerve • supramaximal stimulation of nerve trunk
• intraopening monitoring of CN 7 function during intracranial • not useful in acute setting: (Wallerian degeneration occurs 24-72 hr post trauma)
operation, parotid & otologic surgery • Differentiate neuropraxia VS severe injury

CLINICAL ASPECT OF FACIAL NERVE

INFLAMATORY CHANGES TRAUMATIC FACIAL PARALYSIS CONGENITAL TUMOR
• IDIOPATHIC FACIAL PARALYSIS (Bell’s palsy) • partial/complete • Mobius syndrome • Acoustic neuroma
• INFLAMMATORY OTOGENIC FACIAL • causes: • CN 7 becomes a fibrous tract (no nerve fibers) • usually at cerebellopontine angle
PARALYSIS o temporal bone fracture (vehicular accidents) • CHARGE Syndrome • HISTIOCYTOSIS x
• INFECTION o facial trauma (laceration, stab to CN 7) o Coloboma o Langerhans Cell tumor
o Surgical trauma (iatrogenic) o Heart o young px (5-6 yo), very rare
• TRANSVERESE type: o Choanal atresia o ear discharge (unresolved with med)
o Perpendicular/oblique to petrous bone (origin) o retarded growth o CT scan: mass
o More common to cause complete resection o genital hypoplasia o responsive to chemo only
o Sx: facial asymmetry o ear o no surgery
o Semicircular canal may be involved • CULLP: Congenital unilateral lower lip palsy
• LONGITUDINAL/Horizontal type

IDIOPATHIC FACIAL PARALYSIS
(BELL’S PALSY)
• most common CN 7 paralysis
• unilateral, peripheral (upper & lower face)
! sudden onset (1-2 days)
• progressive onset = consider mass
• spontaneous healing
• Tx; steroid (relieve IAC pressure)
INFLAMMATORY CHANGES
INFLAMMATORY OTOGENIC FACIAL PARALYSIS INFECTION
• spread of infection from middle ear to CN 7 • most common: herpes zoster (Ophthalmicus) & borreliosis
• Complication of otitis, osteomyelitis, mastoiditis • IM
• in low socioeconomic status with cholesteatoma (bone eroded)
Or with clinical mastoiditis (ear discharge + facial paralysis)

HOUSEBRACKMANN FACIAL NERVE GRADING SYSTEM

GRADE I GRADE II GRADE III GRADE IV GRADE V GRADE VI
NORMAL MILD DYSFUNCTION MODERATE DYSFUNCTION MOD-SEVERE SEVERE TOTAL PARALYSIS
DYSFUNCTION DYSFUNCTION
Appearance Normal Slight weakness Obvious difference, Not disfiguring Obvious weakness & Only barely No movement
facial Slight synkinesis Noticeable synkinesis contracture, disfiguring asymmetry perceptible motion
function hemifacial spasm
in all
areas
At rest Normal symmetry & tone Asymmetry
Forehead Mod-good movement Slight-moderate movement None None
Eye Complete closure w/ Complete closure w/ effort Incomplete closure
minimal effort
Mouth Slight asymmetry Slightly weak w/ max effort Asymmetric w/ max effort Slight movement