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$$on %J'E has central connections that can affect .1 ncles !resentation can (e .1 !aralysis 5. 'el.erso&3Rose&thal (&drome - Kare &isease - TK;,D) 1. .1 !aralysis %alternating !aralysis+ sally (ilateral'E 2. E&e$a of the face an& oral cavityE an& 3. .issre& tonge 6 $ay not co$e as a tria& (t !aralysis an& e&e$a of oral cavity only L(me Disease 3 en&e$ic in the Unites States (t not !resent in the Phili!!ines Diagnosis of .1 Disor&er o *# an& PE D&# Chil& congenital ,< acDire& 8ellBs !alsy 3 "/ or "/o steroi&s+ 846H0I s!ontaneos re$ission o Clinical evalation an& gra&ing Chec: the forehea&+ the closre of eyes+ $ove$ent of the lo"er Da&rant >ra&e 6 3 !!er an& lo"er Da&rant !aralysis ,n in6(et"een gra&e "ill (e (ecase of anato$y+ re$e$(er yo have a (ilateral innervation of forehea& thatBs "hy it is less vlnera(le to !aralysis2 o ,ncillary !roce&res %Electro!hysiologic testing' >ive the !rognosis of the !aralysis an& &egree of nerve in<ry >oo& !rognosis) nero!ra#ia Poor !rognosis) nerot$esis o Manage$ent) &e!en&s on ancillary tests2 >oo& !rognosis $e&ical &eco$!ression initially Poor !rognosis srgical &eco$!ression %o!en ! the (one+ loo: for the nerve+ &issect nerve ot of internal a&itory canal+ &eco$!ress nerve+ an& ho!e the !aralysis "ill i$!rove'2 Disclai$er) this is (ase& on &ocBs lectre+ !lease chec: if there are errorsL ;tBs <st a s!!le$ent to Cha!ter 8) Disor&ers of the .acial 1erve fro$ 8oies2 Than:s a&s an& lara for yor notes+ recor&ings+ an& la!to! seL ,&s+ narcole!tic &in a:oL Cara+ roo$$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