Facial Nerve

Paralysis
..

Outlines
Anatomy
Classification
Evaluation
Electrodiagnosis testing
Management
Bells palsy ,Ramse Hunt
syndrome
Temporal bone fracture

Anatomy of Facial
nerve

The facial nerve contains approximately 10,000

fibers
7000 myelinated fibers innervate the muscles of
facial expression, stapedius muscle, postauricular
muscles, posterior belly of digastric muscle, and
platysma
3000 fibers form the nervus intermedius (Nerve of
Wrisberg)

sensory fibers (taste) from the anterior 2/3 of the tongue

taste fibers from soft palate via palatine and greater
petrosal nerve
parasympathetic secretomotor fibers to the parotid,
submandibular, sublingual, and lacrimal gland

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

Cerebral cortex Corticobulbar

tract Facial nucleus (pons)
Upper

face crossed & uncrossed

Lower face crossed only

Nuclear segment

Facial motor nucleus

lower 1/3 of Pons
abducent nucleus
Out from brain stem at pons recess
between olive and inferior
cerebellar peduncle

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

The facial nerve and nervus

intermedius exit the brain stem at
the pontomedullary junction and
travel with CN VIII to enter the
internal acoustic meatus

Internal acoustic canal

Motor facial nerve (medial)

N ervus intermedius (between)
Acoustic nerve (lateral)

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

First genu above oval window

stapes
Second genu beyond middle ear
Out of cranium through
stylomastoid foramen

Mastoid segment
Stylomastoid foramen
Branches

Motor

nerve to stapedius muscle

Chorda tympani nerve between
malleus and incus
secretomotor

: Submandibular &
Sublingual gland
taste fiber : anterior 2/3 of tongue

Extracranial segment

Posterior auricular nerve : auricularis, occipitalis

and sensation at auricular, post auricular area
Branch to posterior belly of digastric muscle
and stylohyoid muscle
T emporal branch : muscle above zygoma
Z ygomatic branch : orbicularis occli
B uccal branch : buccinator and upper lip
M arginal mandibular branch : orbicularis oris and
lower lip
C ervical branch : platysma

Physiology

Efferent fibers : from the motor

nucleus innervate muscles of facial
expression, post-auricular, stylohyoid,
posterior digastric, and stapedius
muscles
Efferent fibers : ANS (preganglionic
parasympathetic fiber)
sphenopalatine ganglion to lacrimal
glands and mucinous glands of nose
submandibular ganglion to
submandibular and sublingual glands

Physiology

Afferent fibers convey taste from

anterior two-thirds of tongue to
nucleus tractus solitarius via lingual
nerve, chorda tympani, and nervus
intermedius.
Afferent fibers mediate sensation
from posterior external auditory canal,
concha, ear lobe, and deep parts of
face

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

neurapraxia ~ Sunderland grade 1

axonotmesis ~ Sunderland grade 2-3
neurotmesis ~ Sunderland grade 4-5

Degeneration

Interruption of the continuity of the axon

separates the distal axon from its metabolic s
ource, the neuron or cell body
Wallerian degeneration of the distal axon
and myelin sheath begins within 24 hours
Macrophages phagocytose degraded myelin
and axons

Regeneration
Complete
Partial
Simple misdirection

Clinical

expression: synkinesis or
associated movement

Complex misdirection
Clinical

expression: mass movement

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

3. Congenital absence of facial

musculature

1. Traumatic

Fractures

Intratemporal

of petrous pyramid
Penetrating injuries
Iatrogenic injuries
2. Neoplastic
Cholesteatoma
Facial neurinomas
Hemangiomas
Meningiomas
Acoustic neurinomas

Intratemporal
3. Infectious

Herpes zoster oticus

Acute otitis media
Chronic otitis media
Malignant otitis externa

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

Central facial paralysis

Upper motor neurone lesion

Movements of the frontal and upper
orbicularis oculi tend to be spared
Because of uncrossed contributions
from ipsilateral supranuclear areas
Involvement of tongue
Involvement of lacrimation and
salivation

Peripheral paralysis
Lower motor neurone lesion
At rest :

less

prominent wrinkles on forehead of

affected side, eyebrow drop, flattened
nasolabial fold, corner of mouth turned
down

Unable to :

wrinkle forehead, raise eyebrow,

wrinkle nasolabial fold, purse lips, show
teeth, or completely close eye

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

To determine the anatomical level of

a peripheral lesion
Lacrimation Geniculate ganglion
Stapedius reflex motor nerve of
stapedius muscle
Taste chorda tympani

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)

Chorda tympani nerve test

Solution of salt, sugar, citrate, quinine or
Electrical stimulation
Compares amount of current require for a
response each side of tongue
Normal : difference < 20 uAmp (thresholds
differening by more than 25%= abnormal)
Total lack of Chorda tympani : No response at
300 uAmp
Disadvantage : False +ve in acute phase of
Bells palsy

M inimal stimulation test

neurapraxia

axonotmesis

neurotmesis

M inimal stimulation test

3.5 mA Wallerian
degeneration

M aximal stimulation test (MST)

neurapraxia
axon

axonotmesis
axon

neurotmesis

M aximal stimulation test (MST)

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

motor unit potential

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

Idiopathic facial palsy

(Bell's Palsy)

Most common cause of facial paralysis

(>50% of case)
Most age 25-30 yrs.
Male : Female = 1 : 1
Left side : Right side = 1 : 1
Unilateral > bilateral
Increase risk in
pregnancy 3.3 times
DM 4.5 times
Recurrent rate 10%
60% have previous URI

Etiology

Unknown
Microcirculatory

failure of vasa

nervorum
Viral infection (HSV)
Ischemic neuropathy
Autoimmune reaction

Entrapment theory

Diagnosis

By exclusion

Criteria :
Paralysis

or paresis of all muscle

groups of one side of the face
Sudden onset
Absence of signs of CNS disease
Absence of signs of ear or CPA
disease

Medical treatment

C orticosteroids :
prednisolone

days

1 mg/kg/day 7-10

C orticosteroids combine with

antiviral drug is better
Acyclovir 400 mg 5 times/day
F amciclovir and valacyclovir 500
mg bid

Surgical treatment
Facial nerve decompression
Indication

Completely

paralysis
ENOG less than 10% in 2 weeks

Appropriate time for surgery is

2-3 weeks after paralysis

Herpes Zoster Oticus

( Ramsay Hunt Syndrome)

3rd most common of peripheral facial

paralysis (10%)
Aged > 60 yrs. or low immune (low CMIR)
Virus travels to the dorsal root extramedullary
cranial nerve ganglion
Infected of HZV at auricular, external
canal or face
Prodromal symptoms very similar to
those seen in Bell's palsy
but usually more severe

Herpes Zoster Oticus

( Ramsay Hunt Syndrome)

Symptoms include severe otalgia,

facial paralysis, facial numbness, and
a vesicular eruption on the concha,
external auditory canal, and palate

Facial paralysis + hearing loss +

vertigo canal paralysis
Pathophysiology & treatment
liked in Bell s palsy

Temporal bone fractures

Longitudinal fracture
Transverse fracture
Mixed fracture

Temporal bone fractures

Signs

bleeding

from the external canal

hemotympanum
step-deformity of the osseous canal
conductive hearing loss (longitudinal
fracture)
sensorineural hearing loss (transverse
fracture)
CSF otorrhea
facial nerve involvement (20% of
longitudinal fractures and 50% of
transverse fractures)

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

: any case have

no poor prognostic factors

Complications

Complications of facial nerve

decompression
dural

tears
conductive or sensorineural hearing loss
vestibular function loss
persistent CSF leaks
meningitis
injury to the anterior inferior cerebellar
artery (AICA) or its branches