Professional Documents
Culture Documents
Paralysis
..
Outlines
Anatomy
Classification
Evaluation
Electrodiagnosis testing
Management
Bells palsy ,Ramse Hunt
syndrome
Temporal bone fracture
Anatomy of Facial
nerve
Anatomy of Facial
nerve
1) Intracranial part
Supranuclear segment
Nuclear segment
Infranuclear segment
Cerebellopontine angle
Internal acoustic canal
Labyrinthine segment
Tympanic segment
Mastoid segment
2) Extracranial part
Supranuclear segment
Nuclear segment
Nervous intermedius
Parasympathetic secretory fibers
arise from superior salivatory
nucleus
These preganglionic fibers travel to
the submandibular ganglion via the
chorda tympani nerve to innervate
the submandibular and sublingual
glands
And to sphenopalatine ganglion via
greater superficial petrosal nerve to
innervate lacrimal, nasal, and
palatine gland
Nervous intermedius
Secretory fibers of lesser superficial
petrosal nerve tranverse tympanic
plexus, synapse in otic ganglion, and
travel via auriculotemporal nerve to
innervate parotid gland
Taste fibers from anterior 2/3 of
tongue reach geniculate ganglion via
chorda tympani nerve and from
there travel to the nucleus of the
tractus solitarius
Submandibular ganglion
Submandibular gland
Infranuclear segment
Cerebellopontine angle
Internal acoustic canal
Labyrinthine segment
Tympanic segment
Mastoid segment
Cerebellopontine angle
Labyrinthine segment
Fallopian canal
Shortest & Narrowest part
Temporal bone
Facial nerve enter fallopian canal until middle ear
First genu
Geniculate ganglion
Branches
Greater superficial petrosal nerve lacrimal
gland
Lessor superficial petrosal nerve parotid
gland
Tympanic segment
Mastoid segment
Stylomastoid foramen
Branches
Motor
: Submandibular &
Sublingual gland
taste fiber : anterior 2/3 of tongue
Extracranial segment
Physiology
Physiology
Classifications of facial
nerve injury
Seddon classification of nerve
injury
Neuropraxia
Axonotmesis
Neurotmesis
Classifications
Sunderland classification of nerve injury
1 damage = Compression
2 damage = Interruption of axoplasm
3 damage = Disruption of myelin
4 damage = Disruption of perineurium,
myelin and axon
5 damage = Transection of nerve
Sunderland
Classification
of nerve injury
Nerve injury
Degeneration
Regeneration
Complete
Partial
Simple misdirection
Clinical
expression: synkinesis or
associated movement
Complex misdirection
Clinical
Differential Diagnosis
1.
2.
3.
Extracranial
Intratemporal
Intracranial
Extracranial
1. Traumatic
Facial lacerations
Blunt forces
Penetrating wounds
Mandible fractures
Iatrogenic injuries
Newborn paralysis
Extracranial
2. Neoplasm
Parotid
tumors
Tumors of the external and middle ear
Facial nerve neurin omas
Metastatic
lesions
musculature
1. Traumatic
Fractures
Intratemporal
of petrous pyramid
Penetrating injuries
Iatrogenic injuries
2. Neoplastic
Cholesteatoma
Facial neurinomas
Hemangiomas
Meningiomas
Acoustic neurinomas
Intratemporal
3. Infectious
4. Idiopathic
Bell's palsy
Melkersson-Rosenthal syndrome
5. Congenital: osteopetroses
Intracranial
1.
2.
3.
Iatrogenic injury
Neoplastic
Congenital
Mobius syndrome
Absence of motor units
History
Onset
Previous symptoms
Complete or incomplete
Unilateral or bilateral
Pain
Underlying disease (vestibulocochlear)
Associate symptoms
Alteration in taste or lacrimation
History
Family history
Trauma
Hx of viral infection
Vaccination
DM
HTN
Pregnancy
Physical examination
ENT exam
Nervous system
Location
Severity
Evaluation of Facial
paralysis
Clinical feature
Central VS Peripheral facial paralysis
Complete head and neck examination
Cranial nerve evaluation
Electrodiagnostic testing
Topographic diagnosis
Peripheral paralysis
Lower motor neurone lesion
At rest :
less
Unable to :
House-Brackmann grading
system
Grade I - Normal
Grade II - Mild dysfunction, slight weakness on
close inspection, normal symmetry at rest
Grade III - Moderate dysfunction, obvious but
not disfiguring difference between sides, eye can
be completely closed with effort
Grade IV - Moderately severe, normal tone at
rest, obvious weakness or asymmetry with
movement, incomplete closure of eye
Grade V - Severe dysfunction, only barely
perceptible motion, asymmetry at rest
Grade VI - No movement
Topographic Diagnosis
Schirmer's Test
Geniculate ganglion & petrosal nerve
function test
Schirmers test +ve when
Affected side shows less than half the
amount of lacrimation seen on the normal
side
Sum of the lengths of wetted filter paper
for both eyes less than 25 mm
Lesion at or proximal to the geniculate
ganglion
Stapedius reflex
Nerve to stapedius muscle test
Impedance audiometry can record
the presence or absence of
stapedius muscle contraction to
sound stimuli 70 to 100 dB above
hearing threshold
An absence reflex or a reflex less
than half the amplitude is due to a
lesion proximal to stapedius nerve
Taste
(Electrogustometry)
neurapraxia
axonotmesis
neurotmesis
3.5 mA Wallerian
degeneration
neurapraxia
axon
axonotmesis
axon
neurotmesis
5 mA
2
facial nerve
12
73
facial nerve
misdirection
E lectroneurography (ENOG )
MST
summating potential
amplitude
amplitude SP
5-10
90-95 facial nerve
misdirection
E lectromyography (EMG)
facial palsy 10
Wallerian degeneration
fibrillatioin
facial nerve
Limitation of Electrodiagnostic
testing
1.
2.
3.
72
EMG
10
(
EMG)
Management
Extracranial
etiology
Trauma
Iatrogenic
Neoplasm
Intratemporal
etiology
Fracture
Iatrogenic
Neoplasm
Idiopathic
(Bells palsy)
Infection
Etiology
Unknown
Microcirculatory
failure of vasa
nervorum
Viral infection (HSV)
Ischemic neuropathy
Autoimmune reaction
Entrapment theory
Diagnosis
By exclusion
Criteria :
Paralysis
Medical treatment
C orticosteroids :
prednisolone
days
1 mg/kg/day 7-10
Surgical treatment
Facial nerve decompression
Indication
Completely
paralysis
ENOG less than 10% in 2 weeks
Signs
bleeding
Longitudinal VS
Transverse
Type of
injury
Incidence
Site of
injury
Longitudi
nal
70-90%
Temporal
, Parietal
area
Transver
se
10-20%
Occipital
, Frontal
area
Origin of
Direction
fracture site
of
injury
Temporal
squama
Foramen
magnum
Posterosupe
rior of EAC
cross roof of
middle ear
along
carotid
canal
anterior to
labyrinthine
capsule
Between
various
foramen
Jugular F.
Hypoglosal
F.
Labyrinthin
e capsule
Insertion
middle
middle
cranial fossa cranial fossa
Tympanic
mb.
Middle ear
Inner ear
Hearing
loss
CHL
No
hemotympanum
SNHL
Common
Facial
paralysis
Onset
20-25 %
Delayed,
transient
Site of
lesion
Tympanic
segment ,
Perigenicul
ate
ganglion
CSF
otorrhea
No
50%
Immediate
,
permanent
Labyrinthin
e segment
Common
Cardinal
S&S
1.Bleeding
from ear
2.CHL
3.Battles
sign
1.Vertigo&Nyst
agmus
2.SNHL
3.Facial
paralysis
4.Hemotympan
um
CT-scan
Axial &
sagital
section
Coronal &
20degree
coronal oblique
section
Prognosis
I mmediate onset paralysis : poor
prognosis
D elayed onset paralysis : good
prognosis
All case of paralysis electrical
testing
Treatment
Surgery
is treatment of choice
Indications for facial nerve
exploration
incomplete paralysis
iatrogenic paralysis
Contraindications
Complications
tears
conductive or sensorineural hearing loss
vestibular function loss
persistent CSF leaks
meningitis
injury to the anterior inferior cerebellar
artery (AICA) or its branches