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ENT Disorders of the Facial Nerve

USTMED Sec C 2008 7/10/06


Physiology of the facial nerve
Diseases affecting the facial nerve
Clinical evalation of !atient "ith facial nerve !aralysis
FACIAL NERVE
- !ro#i$al to the 8
th
nerve %a&itory nerve'
- enters the $i&&le ear via the internal a&itory canal
- gives off 2 (ranches in the $i&&le ear) sta!e&is an& chor&a
ty$!ani
- *as $otor+ sensory+ an& !arasy$!athetic co$!onents
Motor) Mscles of facial e#!ression
Sensory) ,nterior 2/- of tonge
Parasy$!athetic (ranches) Secretory fnctions of
salivary glan&
- *as central connections) $otor an& sensory nclei of facial
nerve
Facial muscles
.acial nerve gives off $otor (ranches to $scles of
e#!ression
The !!er $scles are (ilaterally controlle& (y !!er
ncles of facial e#!ression / !articlarly+ te$!oral
an& 0ygo$atic (ranches+ "hich are $otor (ranches
of .1
FACIAL NERVE PHYI!L!"Y
# $asic Com%o&e&ts of the Fu&ctio& of FN
12 "e&eral $ra&chial 'otor 3 4 !eri!heral $otor (ranches
- 5ygo$atico6te$!oral (ranch %0ygo$atic 7 te$!oral
(ranches'
- 8ccal (ranch
- Man&i(lar (ranch
- Cervico$an&i(lar (ranch
22 Visceral 'otor 3 secretory !art of .1
- 1
st
(ranch goes to the s!heno!alatine ganglion /
secretory fnction of lacri$al glan&s as "ell as the glan&s
of the soft an& har& !alate in the oral cavity
control secretions of saliva+ soft an& har&
!alate+ an& $inor salivary glan&s an&
controls lacri$al secretions of eyes
- 2
n&
(ranch of visceral $otor 3 goes "ith the chor&a
ty$!ani an& gives off secretory $otors to the
s($an&i(lar an& s(lingal glan&s
-2 %ecial e&sor( 3 refers to the chor&a ty$!ani
- res!onsi(le for the sensation of taste on anterior 2/- of
tonge
92 "e&eral e&sor( 3 gives off sensory fi(ers to the concha of the
aricle/!inna+ as "ell as the s:in of the !osterior !art of
the aricle2
- ;f yo have !aresthesia or hy!eresthesia of the sensory
co$!onent+ this is the seg$ent res!onsi(le for this !art of
the facial nerve2
Distri)utio&)
.1 enters ;nternal a&itory canal 3 gives off t"o $a<or (ranches
%$inor (ranch) (ranch to the sta!e&is $scle'
1. chor&a ty$!ani+ together "ith the !arasy$!athetic secretory
innervation 3 res!onsi(le for the sensory !art of the anterior
2/- of the tonge
2. $ain (ranch 3 gives off the $otor co$!onent via the
stylo$astoi& fora$en
- anato$ically i$!ortant (ecase "hen yo &o yor
electro!hysiologic evalation of .1+ yo !t in yor
nee&le on the stylo$astoi& fora$en area
Ph(siolo*(+ ummar(
1. 8ranchial Motor 3 s!!lies $scles of facial e#!ression+
!osterior (elly of the &igastric an& stylohyoi& an& the
sta!e&is $scle
2. =isceral Motor 3 !arasy$!athetic+ gives off innervation to
the lacri$al glan&s via the s!heno!alatine ganglion+
s($an&i(lar an& s(lingal glan& via the ncles of the
chor&a ty$!ani
3. S!ecial Sensory 3 !ain sensation anterior 2/- of the
tonge via the soft !alate
4. >eneral Sensory 3 sensation to concha of aricle an& s:in
(ehin& the ear
;f yo see a !atient "ith this $anifestation %signs of facial
nerve !aralysis'+ volntary $ove$ent "ill illicit no
$ove$ent on the affecte& si&e2 ;f affecte& si&e is on the
left !art+ the local !art on the si&e / there is ina(ility to
close left eye+ no $ove$ent of the shallo" nasola(ial fol&+
or(icalris oris an& forehea& of affecte& si&e are
i$$o(ile2
,hat do (ou do for %atie&ts -ith this .i&d of %aral(sis/
1. Clinical Evalation
a. To!ognostic Testing
b. >ra&ing of .acial 1erve Dysfnction
2. Electro!hysiologic Testing
CLINICAL EVAL0ATI!N
A1 To%o*&ostic Testi&* 3 clinical evalation
6 significance) to locali0e lesion clinically
1. chirmer Test
- evalate the tearing fnction of the eye
- 1st (ranch of .1 is the greater superficial petrosal nerve+
"hich is involve& in the lacri$ation or innervation to the
secretory fnction of the lacri$al glan&2
- Test lacri$ation (y !tting Schir$er !a!er stri!s on (oth
eyes2 ;t a(sor(s tears fro$ (oth eyes+ s!ecifically the
forni# of the lo"er con<nctiva
- Measre !art of !a!er that is "et (y the lacri$ation2
%?' Difference of $ore than 1/- is significant / no
lacri$ation (ecase lesion is a(ove greater
s!erficial !etrosal nerve
%?' 1or$al lacri$ation / lesion is lo"er than the
(ranching of the greater s!erficial !etrosal nerve
2. ta%edial Refle2 Test
- Sta!e&ial (ranch of .1 is in the $i&&le ear2
- Uses an i$!e&ance a&io$eter
- .ro$ 8oies) , lo& tone %40680 &(' is !resente&+ either to
the i!silateral or the contralateral ear+ "hich evo:es a
refle# $ove$ent of the sta!e&is $scle2 This changes
the tension on the ty$!anic $e$(rane an& reslts in a
change in i$!e&ance of the ossiclar chain2
- @hen tone is !resente& to the o!!osite+ nor$al6hearing
ear+
%?' sta!e&ial refle# / lesion is lo"er than the level of
(ranching of the sta!e&ial (ranch
%6' sta!e&ial refle# / lesion is a(ove the sta!e&ial
(ranch
3. Taste Test
- tests the fnction an& (ilaterality of the innervation of the
chor&a ty$!ani (y co$!aring (oth si&es of the tonge2
- Atsi&e $i&&le ear+ .1 gives off the chor&a ty$!ani2
- Sgar or salt on one si&e of the tonge an& co$!are to
other si&e2
%?' (ilateral taste / lesion is lo"er than the (ranching off
of the chor&a ty$!ani
%?' &ecrease& sensation on affecte& si&e / lesion is
a(ove the (ranching of chor&a ty$!ani
4. alivar( Flo- Rate a&d %H
- The lesser superficial petrosal nerve of .1 gives off a (ranch
that goes "ith the chor&a ty$!ani an& innervates the secretory
$otor of the flo" of saliva+ !articlarly the s($an&i(lar an&
s(lingal2
- The s($an&i(lar glan& has a @hartonBs &ct that yo can
cannlate2
- Measre the flo" of saliva+ (ilaterally2
%?' Cesser flo" an& change in !* of saliva / lesion a(ove or
in the chor&a ty$!ani an& lesser s!erficial !etrosal nerve
(efore it e#its throgh the stylo$astoi& fora$en
;n cases "here yo have otitis $e&ia as the case of facial
!aralysis+ to!ognostic testing is sefl2
8t in 8ellBs !alsy %$ost co$$on for$ of facial nerve
!aralysis'+ lesion is a(ove the greater s!erficial !etrosal
nerve / there is &ec2 lacri$ation+ no sta!e&ial refle#+ &ec
!ain sensation on anterior 2/- of the tonge an& &ec flo"
Co$!lete facial !aralyis 3 a(sent tone in the !!er an&
lo"er Da&rants of the face
$1 House3$rac.ma& "radi&* of Facial Nerve D(sfu&ctio&
stan&ar& gra&ing of .1 !aralysis+ acce!te& niversally
"rade 41 1or$al $ove$ent
"rade 51 Slight) Mil& syn:inesis %"hen !atient volntarily
$oves face' an& asy$$etry
"rade 61 Mo&erate) o(vios "ea:ness+ asy$$etry+ goo& eye
closre %(ecase (ilaterally innervate&E intact
!!er face+ !aralysis on lo"er Da&rant'
"rade #1 Mo&erately o(vios+ no forehea& $otion
"rade 71 Severe+ cannot close eye2
"rade 81 Total) Co$!lete facial !aralysis+ a(sent tone
ELECTR!PHYI!L!"IC TETIN"
1. Nerve E2cita)ilit( Test
,vaila(le in the Phil+ co$$on an& affor&a(le
"atch for $ove$ent of facial $scles as yo intro&ce
the sti$li
!ositive test after 7619 &ays
reslts of this test are not significant if test is given
i$$e&iately after !aralysisE yo &onBt &o this test earlier
(ecase it "ill (e a false !ositive
%?' test / significant only after 162 "ee:s after onset of
!aralysis
2. 'a2imal timulatio& Test
- More sensitive than e#cita(ility testing
- give $a#i$$ sti$li+ see if there is $ove$ent
- if %?' $ove$ent+ it "ill hel! yo !rognosticate
- evalate the nerve as to "hat :in& of in<ry it has sffere&
Fsee histologic classificationG
3. Electro&euro*ra%h(
- $ost infor$ative test
- Metho&) !t sti$li &irectly on nerve on the stylo$astoi&
fora$en area
- Pt nee&le via s:in+ ho!ing it hits the facial nerve as it
e#ists the stylo$astoi& fora$en an& then $easre
in&ivi&ally the &ifferent $scles that is innervate& (y the
4 !eri!heral (ranches of the .1
- sti$late nerve / $easre res!onse of $scles of 4
(ranches
- 8eco$es %?' only 967 &ays after in<ry+ so !erfor$e& at that
ti$e2
e2g2 see if yo have in<ry to !erineri$ only of the a#on
itself or a &ifferent section
- sensitive enogh to &etect &egeneration of the nerve only after
a fe" &ays
4. Electrom(o*ra%h(
nee&le on the $scle itself an& see if there is $ove$ent
retaine& in the $scle
significant only 162 "ee:s after in<ry
1erve E#cita(ility Test+ Ma#i$al Sti$lation an&
Electro$yogra!hy reDeste& only after 162 "ee:s+ "hile
Electronerogra!hy reDeste& 967 &ays after onset of
nerve in<ry2
TYPE !F NERVE IN90RY 3 histologic classification
1. 1ero!ra#ia 3 1
st
&egree in<ryE
(est !rognosis
2. ,#onot$esis
3. En&onerot$esis
4. Perinerot$esis
5. 1erot$esis or co$!lete transection of nerve 3 co$!lete
&estrction of neral continityE "orst !rognosis
CAUSES OF PARALYSIS
1. Co&*e&ital
12 $irth trauma
6 $ost co$$on
6 es!ecially in force!s &elivery+ "here the instr$ent is
&esigne& to rn along the si&e of s:ll+ in the !rocess
in<res the stylo$astoi& fora$en area an& the (a(y
co$es ot "ith !aralysis
22 'o)ius s(&drome
6 syste$ic
6 facial !aralysis is only a !art of the syn&ro$e
6 (a(y co$es ot "ith (ilateral .1 !aralysis assoc "ith
other cranial nerve !aralysis eg2 C1 -+ C1 4
2. Ac:uired
1. $ell;s %als(
- $ost co$$on
- sally associate& "ith a viral infection %not her!es+
sally a syste$ic infection' ' that goes to ncles of
the facial ncles 3 !!er central lesion 6 %lesion is
a(ove the greater !etrosal nerve'
- 846H0I s!ontaneos recovery
- Mgt) Usally give steroi&s Pre&nisone 80 $g/& for 4
&ays then ta!er it &o"n / to &eco$!ress facial nerve
&e to infla$$ation
2. Trauma
- Secon& $ost co$$on
- .ractre of te$!oral (one
- Congit&inal an& vertical fractres
- vertical) along te$!oral (one 3 assoc "ith facial nerve
!aralyisis
- hori0ontal (one fractre 3 not assoc "/ .1 !aralysis
- oftenti$es not a clear6ct fractre co$!on&
fractre are sally seen "ith the vertical co$!onent
assoc "ith .1P
- Mgt) ;nitially+ $e&ical &eco$!ression "ith steroi&s2
@ait for 1 "ee:+ if gra&al &eterioration of the nerve
contines+ !rocee& "ith srgical &eco$!ression2
3. Her%es <oster oticus
viral inf#n !resents "ith vesicles in the e#ternal a&itory
canal an& !inna assoc "ith .1P
Mgt) acyclovir 1 g T;D for 4 & together "ith steroi&s
*er!es 0oster is the only viral inf#n that can (e treate&
$e&ically+ "e &o not &o srgery
4. Tumors
- Acoustic &euroma %a&itory nerve' 3 $ost co$$on
t$or that cases .1P
&e to !ro#i$ity of facial nerve to the a&itory
canal
if the t$or gro"s in the internal a&itory canal+
the .1 can (e &estroye& (y the gro"ing t$or
6 $rai& tumor 3 $ost co$$on %J'E has central
connections that can affect .1 ncles
!resentation can (e .1 !aralysis
5. 'el.erso&3Rose&thal (&drome
- Kare &isease
- TK;,D)
1. .1 !aralysis %alternating !aralysis+ sally
(ilateral'E
2. E&e$a of the face an& oral cavityE an&
3. .issre& tonge
6 $ay not co$e as a tria& (t !aralysis an& e&e$a of
oral cavity only
L(me Disease 3 en&e$ic in the Unites States (t not !resent in the
Phili!!ines
Diagnosis of .1 Disor&er
o *# an& PE D&#
Chil& congenital
,&lt acDire&
8ellBs !alsy 3 "/ or "/o steroi&s+ 846H0I s!ontaneos
re$ission
o Clinical evalation an& gra&ing
Chec: the forehea&+ the closre of eyes+ $ove$ent of the
lo"er Da&rant
>ra&e 6 3 !!er an& lo"er Da&rant !aralysis
,n in6(et"een gra&e "ill (e (ecase of anato$y+
re$e$(er yo have a (ilateral innervation of forehea& thatBs "hy it
is less
vlnera(le to !aralysis2
o ,ncillary !roce&res %Electro!hysiologic testing'
>ive the !rognosis of the !aralysis an& &egree of nerve
in<ry
>oo& !rognosis) nero!ra#ia
Poor !rognosis) nerot$esis
o Manage$ent) &e!en&s on ancillary tests2
>oo& !rognosis $e&ical &eco$!ression initially
Poor !rognosis srgical &eco$!ression %o!en ! the
(one+ loo: for the nerve+ &issect nerve ot of internal a&itory canal+
&eco$!ress nerve+ an& ho!e the
!aralysis "ill i$!rove'2
Disclai$er) this is (ase& on &ocBs lectre+ !lease chec: if there are errorsL
;tBs <st a s!!le$ent to Cha!ter 8) Disor&ers of the .acial 1erve fro$
8oies2
Than:s a&s an& lara for yor notes+ recor&ings+ an& la!to! seL ,&s+
narcole!tic &in a:oL Cara+ roo$$ateL Pasensya na sa "or$6threat sa la!to!
$oL Sorry !oL A:ay lang na$an &i (aJ 1a:ita $o na$an ang &a!at $a:ita
sa s( :o+ rightJ *eheL

*i sheilalyn+ rochelyn+ ser!ilyn+ a&rilyn+ &ennilyn+ al&"ilyn+ $arilyn+
:atrilyn+ $arcolyn+ teenilyn+ chin:ylyn+ <a$elynL Dahil a:o g$a"a ng
han&ot+ pam ang ilalagay :o &itoL

MeheyL @ee:en& naL ,nsara! $atlogLLL ,ral $a(ti+ class$atesL
!a$

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