Periferne paralize

facijalnog živca

Elvir Zvrko

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N. facialis- topografija
118 Cranial Nerves

Table VII–1 Nerve Fiber Modality and Function of the Facial Nerve
N. facialis- topografija
• Mješoviti živac- motorna, sekretorna i gusto- receptorna vlakna
Nerve Fiber Modality Nucleus Function
General sensory Spinal of the trigeminal To carry sensation from the skin of the concha of the
(afferent) nerve auricle, a small area of skin behind the ear, and
possibly to supplement V3, which carries sensation
from the wall of the external auditory meatus and

• Intrakranijalni segmentSpecial sensory

(afferent)
Solitarius (rostral
gustatory portion)
the external surface of the tympanic membrane
For taste sensation from the anterior
two-thirds of the tongue
• N. intermedius ili VII bis živac je drugi dio n. facialisa
Branchial motor Motor of cranial nerve VII To supply the muscles of facial expression (ie,
(efferent) frontalis, occipitalis, orbicularis oculi, corrugator

Motorna vlakna (10000-13000) polaze iz jedara u ponsu

supercilii, procerus, nasalis, levator labii superiorus,
• levator labii superioris alaeque nasi, zygomaticus
major and minor, levator anguli oris, mentalis,
depressor labii inferioris, depressor anguli oris,
buccinator, orbicularis oris, risorius, and platysma).
In addition, the branchial motor fibers supply the
stapedius, stylohyoid, and posterior belly of
• Visceromotorna vlakna koja inervišu gl. lacrimalis, sve
• Obilaze oko jedra n. abducensa i združena u živac napuštaju
Visceral motor
(parasympathetic
Superior salivatory
(lacrimal)
digastric muscles
For stimulation of the lacrimal, submandibular, and
sublingual glands as well as the mucous membrane
sluzokožne žljezde odgovarajuće polovine nosne duplje,
moždano stablo u fossa postpontina kao i gl. submandibularis i gl. sublingvalis
efferent) of the nose and hard and soft palates

Abducens nucleus (CN VI — somatic motor)

© L. Wilson-Pauwels
Nucleus solitarius rostral portion
(special sensory)
Spinal nucleus of the
• Viscerosenzitivna vlakna koja nose gusto receptorni
osjećaj iz pečurkastih papila jezika
trigeminal nerve
(general sensory)

Motor nucleus
of CN VII
(branchial motor)

PONS Superior salivatory

(lacrimal) nucleus
CN VIII
(visceral motor/
parasympathetic)
CN VII

Nervus
intermedius Nucleus solitarius
portion of VII (caudal portion)
(visceral sensory)

Figure VII–2 Nervus intermedius—fibers spread apart.

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N. facialis- topografija N. facialis- topografija

• Timpanični segment
• Intrameatalni segment • Horizontalno i unazad kroz srednje uvo, iznad stapesa i blizu LPK,
prekriven tankom kosti
• Sa VIII živcem prolazi kroz
unutrašnji slušni hodnik • Mastoidni segment

• Labirintni segment • Nakon drugog koljena naglo savija nadolje, spušta se vertikalno do
stilomastoidnog otvora
• Odvaja se n. petrosus maior sa
sekretornim vlaknima za lakrimalne • Odvaja se horda timpani
žlijezde i sluzokožne žlijezde nosa
• Ekstrakranijalni segment
• Savija oštro put nazad čineći
ganglion geniculi- prvo koljeno • Ulazi u parotidnu žlijezdu između površnog i dubokog režnja, 2
završna stabla: gornje i donje, koja se granaju u “pes anserinus”

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Etiologija perifernih paraliza
• Zapaljenske (najčešće otogene)
• Traumatske (kranijalna trauma, na nivou lica)
• Tumorske (cerebralno stablo, parotidna žlijezda)
• Infektivne (Lajmska bolest, infektivna mononukleoza)
• Neurološke (Gulliain- Barre- ov sindrom)
• Sistemske (sarkoidoza)
• Idiopatske (Bellove)- a frigore
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Dijagnostička procedura
Ispitivanje uzroka i stepena lezije
• Anamneza
• Klinički pregled (ORL, neurolog, internista, infektolog,
oftalmolog)
Audiološka i vestibulološka ispitivanja
• expression. A, Frontalis muscle. B, Orbicularis oculi
136 Cranial Nerves
• Hematološka ispitivanja (KS, urea, glikemija)
Radiološka ispitivanja (Stenvers, Town, CT, MR)
A B
• 2. Taste from the Taste Buds
• UZ parotidne žlijezde
C (Figure VII–16B). The patient must rinse his mouth out with water before repeat-
• Elektrostatus i elektromiografija
9 the mandible downward over the clavicle onto the anterior thoracic wall.
Periferne paralize facijalisa
uzrokovane tumorima
• Obično se razvija progresivno
• Infiltrativno dejstvo malignih tumora ili kompresija benignim
tumorima
• Maligni tumori parotidne žlijezde, karcinomi spoljašnjeg i srednjeg
uva, benigni tumori PCU, glomus tumori
• Kod nepoznatih tumora potrebno ispitivanje
• Isto važi i za “idiopatsku” paralizu koja se ne povlači za 3 mjeseca
• Kod poznatih tumora- ukazuje na širenje ili recidiv tumora
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the greater petrosal nerve.
Salivary Submandibular and sublingual
CNS nucleus glands via the nervus intermedius
Meatal and chorda tympani
Internal
Solitary foramen
porus
Motor facial tract acusticus Afferent gustatory
nucleus nucleus
Taste buds on anterior two-
thirds of tongue via the chorda
Lingual ner- tympani
Second genu of facial nerve
ve, tongue
Afferent somatosensory
Chorda Stapedial nerve Posterior meatal wall via the
tympani posterior auricular nerve
Submandibular Frontal branch
ganglion
(submandibular
and sublingual
glands)
Ophthalmic
Stylomastoid branch
Intrameatal segment
foramen
Labyrinthine segment
Tympanic segment
Asimetrija lica
Klinička slika
Oral branch
• Posterior
auricular nerve
Mastoid segment
• Ne može da nabere čelo
• Ne može da zatvori oko (Bellov
fenomen)
• Obrva spuštena
• Zbrisana nazolabijalna brazda
• Spušten ugao usana
• Mimična muskulatura mlitava
Probst-Grevers-Iro, Basic Otorhinolaryngology© 2006 Thieme
All rights reserved. Usage subject to terms and conditions of license.
• Hrana zaostaje između vilice i obraza
• Smanjena sekrecija suza
Dijagnostička procedura
136 Cranial Nerves
Topografsko ispitivanje mjesta lezije
• Schirmer- ov test- sekrecija suzne žlijezde stavljanjem 5cm
A B
dugačke trake lakmus papira u konjunktivalnu vreću
Figure VII–15 Clinical tests for the muscles of facial
Refleks stapedijusa- timpanometrija
C muscle. C, Orbicularis oris muscle.
•
result in burrowing of the eyelashes and the examiner should be unable to open the
patient’s eyes when the patient resists (Figure VII–15B). The buccinator and orbicu-
laris oris are tested by asking the patient to press the lips firmly together. If there is
full strength, the examiner should be unable to separate the patient’s lips (Figure
VII–15C). The platysma can be tested by asking the patient to clench the jaw and
the examiner should see the tightening of the muscle as it extends from the body of
the mandible downward over the clavicle onto the anterior thoracic wall.
• Gustometrija
This is a special sensory nerve that carries taste sensation from the tongue in the
Sijalometrija- salivarna funkcija kateterizacijom Wharton-
chorda tympani to the nucleus solitarius via the nervus intermedius. This modality
is assessed using a stick with a piece of cotton moistened in a sugary or salty solu-
tion. The patient is asked to protrude his tongue and the examiner touches his •
tongue on one side with the solution (Figure VII–16A). Before the patient returns
ovog kanala
his tongue into his mouth, he is asked to report what he tasted by pointing to the
appropriate text on a sign, and then the examiner applies the solution to the other
sideClinical
Figure VII–15 of histests
tongue
for theand asks ofthe
muscles patient if there is any difference between the two sides
facial
expression. A, Frontalis muscle. B, Orbicularis oculi
muscle. C, Orbicularis oris muscle.
ing the test with the next solution.
result in burrowing of the eyelashes and the examiner should be unable to open the
patient’s eyes when the patient resists (Figure VII–15B). The buccinator and orbicu-
laris oris are tested by asking the patient to press the lips firmly together. If there is
full strength, the examiner should be unable to separate the patient’s lips (Figure
VII–15C). The platysma can be tested by asking the patient to clench the jaw and
the examiner should see the tightening of the muscle as it extends from the body of
2. Taste from the Taste Buds
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This is a special sensory nerve that carries taste sensation from the tongue in the
chorda tympani to the nucleus solitarius via the nervus intermedius. This modality
is assessed using a stick with a piece of cotton moistened in a sugary or salty solu-
tion. The patient is asked to protrude his tongue and the examiner touches his
tongue on one side with the solution (Figure VII–16A). Before the patient returns
his tongue into his mouth, he is asked to report what he tasted by pointing to the
appropriate text on a sign, and then the examiner applies the solution to the other
side of his tongue and asks the patient if there is any difference between the two sides
(Figure VII–16B). The patient must rinse his mouth out with water before repeat-
ing the test with the next solution.
Periferne paralize facijalisa
uzrokovane infekcijom
• Akutni otitis (rijetko)
• PPF koja komplikuje hronični otitis sa holesteatomom- hitno hirurško
liječenje
• PPF koja komplikuje hronični otitis bez holesteatoma- sumnja na TBC,
Wegener-ovu bolest
• PPF koja komplikuje upalu spoljašnjeg uva- sumnja na maligni otitis
eksternu
• Herpes zoster (ako je PPF praćena visokom TT ili simptomatologijom od
VIII kranijalnog živca)
• Lajmska bolest (mogućnost pojave uboda krpelja)
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 Belova paraliza
• Unilateralna PPF nepoznatog uzroka i bez oštećenja drugih
kranijalnih nerava
• Najčešći oblik PPF- u 75% slučajeva
• Incidencija: 20 na 100.000 stanovnika
• Et: nepoznata, teorije: ishemija živca, virusna infekcija (HSV),
autoimunost, larvirani oblik polineuropatije, hladnoća i drugi
nepoznati uzroci
• Patogeneza: otok facijalnog nerva (najizraženiji u predjelu
introitusa facijalnog kanala), i poremećaj njegovog krvotoka
Belova paraliza
• Najčešće izloženost hladnoći ili rashlađivanju glave i lica:
vožnja automobilom pored otvorenog prozora, mokra kosa,
spavanje pored otvorenog prozora itd.
• Često prethodi bol u uvu
• Jednostrana iskrivljenost lica- ne može da zatvori oko, ne
nabira čelo, pri pokazivanju zuba paretična strana se ne
kreće
• Brzi oblik- PPF se razvije tokom 3-4 dana
• Spori oblik- PPF se razvije tokom 2 nedjelje

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Belova paraliza Belova paraliza- terapia

• PPF je kompletna u 70% slučajeva • Konzervativna- tokom 1- 2 mjeseca

• Uvijek je zahvaćena frontalna grana • Vitaminska terapija

• Moguća hiperakuzija zbog paralize stapedijalnog mišića • Antivirusna terapija

• Problemi sa okom (iritacija, keratitis) zbog poremećnog refleksa • Vazodilatorna terapija

treptanja
• Kortikosteroidna terapija- jedina kod koje postoje dokazani
• Epifora zbog poremećene funkcije m. orbicularis occuli pozitivni terapijski efekti

• Komplikacija: oštećenje kornee zbog smanjene sekrecija i lagoftalmusa. • Fizikalna terapija

Th: vlaženje oka
• Hirurška- dekompresija n. facialis-a u labirintarnom dijelu kanala od
• Dg: isključenje svih drugih poznatih uzroka introitus canalis facialis do gangliona geniculi- ako nema znakova
oporavka nakon 2 mjeseca od početka PPF

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Belova paraliza- prognoza

• 75% bolesnika ima spontan i potpuni oporavak tokom 3–
6 nedjelja

• Oko 10% oboljelih ima minimalne posljedice

• Kod 10- 15% ostaju ili parcijalne paralize ili se javljaju

posljedice nepovoljnog oporavka (hemifacijalnI spazam,
sinkinezije, suzenja prilikom žvakanja, glavobolje)

• Klinički tok oporavka tokom 1– 2 mjeseca od nastanka

bolesti je jedini realni znak koji može pouzdano pokazati koji
su bolesnici u grupi onih koji se neće spontano oporaviti

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