Seminar presented by :-

Serene Batra, MDS 1styr [batch of

2010].
Dept of Oral & Maxillofacial Surgery,
B.R.S Dental College
Contents
Introduction
Development
Composition of facial nerve-types of fibres
Nuclei i.r.t facial nerve
Central connections of facial nerve
Facial nerve-segmental description
Course anatomy
Branches of communication
Branches of distribution
Ganglia i.r.t facial nerve
Course anomalies
Surgical anatomy & surface landmarks
Nerve injury-sunderlands classification
Facial paralysis
Syndromes assosciated with facial nerve
Other conditions assosciated with facial nerve
References
INTRODUCTI
ON
 INTRODUCTION
The facial nerve is a nerve which controls the muscles on the side
of the face. It allows us to show expression, smile, cry, and wink.
Injury to the facial nerve causes a socially and psychologically
devastating physical defect; treatment may require extensive
rehabilitation or multiple procedures.

The facial nerve is the seventh of the twelveCRANIAL NERVE.

Facial Nerve is a mixed nerve consist of Large motor root called as

FACIAL NERVE PROPER and a small sensory root called as NERVUS
INTERMEDIUS.
The facial nerve is composed of approximately 10,000 neurons,
7,000 of which are myelinated and innervate the nerves of facial
expression. Three thousand of the nerve fibers are somatosensory
and secretomotor and comprise the nervus intermedius.
DEVELOPME
NT
DEVELOPMENT

Facial Nerve developed from 2nd branchial arch.

Facial nerve course, branching pattern, and anatomical

relationships are established during the first 3 months
of prenatal life

The nerve is not fully developed until about 4 years of

age

The first identifiable FN tissue is seen at the third week

of gestation-facioacoustic primordium or crest
 Facial Nerve Embryology-4th
Week
By the end of the 4 week, the facial and acoustic
th

portions are more distinct.

The facial portion extends to
placode
The acoustic portion terminates on
otocyst
Early 5th week, the geniculate ganglion forms
- Proximal portion of premordium becomes less
Facial nerve embryology:
cellular and more fibrous 5 th

- Week
Distal portion:
- Distal part of primordium separates into 2
branches: main trunk of facial nerve and chorda
tympani
- 1-caudal course into 2nd pharyngeal arch Main
trunk of facial nerve.
2- curves rostrally into 1st arch chorda tympani.
 Facial nerve embryology: 7th
week
Early 7th week, geniculate ganglion is well-
defined and facial nerve roots are recognizable
The nervus intermedius arises from the ganglion
and passes to brainstem. Motor root fibers pass
mainly caudal to ganglion.
Facial Nerve Embryology : 8th
Week
By 8th wk it has joined with DEEP petrosal nerve.

Nerve to stapedius seen by 8th week

Early 8th week,temporofacial and cervicofacial

divisions
Late 8th week, 5 major peripheral subdivisions
present
Fibers Associated
With Facial Nerve
Special Visceral Efferent Branchial
Motor Fibers
Premotor cortex motor cortex
corticobulbar tract bilateral facial motor
nuclei (pons) facial muscles
Stapedius, stylohyoid, posterior digastric,
buccinator
General Visceral
Efferent/Parasympathetic
Superior salivatory nucleus (pons) nervus
intermedius greater/superficial petrosal nerve
facial hiatus/middle cranial fossa joins deep
petrosal nerve (symp fibers from cervical plexus)
thru pterygoid canal (as vidian nerve)
pterygopalatine fossa spheno/pterygopalatine
ganglion postganglionic parasympathetic fibers
joins zygomaticotemporal nerve(V2) lacrimal
gland & seromucinous glands of nasal and oral
cavity
Superior salivatory nucleus nervus intermedius
chorda joins lingual nerve submandibular
ganglion postganglioic parasympathteic fibers
submandibular and sublingual glands
Special Visceral
Postcentral gyrus nucleus solitarious
Afferent/Taste
nervus intermedius geniculate ganglion
chorda tympani joins lingual nerve
anterior 2/3 tongue, soft and hard palate
General Sensory
Afferent/Sensory
Sensation to auricular concha, EAC wall, part of
TM, postauricular skin
Cell bodies in geniculate ganglion
Brancial motor Supplies the muscles of facial
(special expression; posterior belly of
visceral digastric muscle; stylohyoid,
efferent) and stapedius.

Visceral motor Parasympathetic innervation of

(general the lacrimal, submandibular,
visceral and sublingual glands, as well
efferent) as mucous membranes of
nasopharynx, hard and soft
palate.

Special Taste sensation from the

sensory anterior 2/3 of tongue; hard
(special
afferent) and soft palates.

General General sensation from the

sensory skin of the concha of the
(general auricle and from a small area
somatic behind the ear.
afferent)
Nuclei
Associated With
Facial Nerve
 Nuclei i.r.t
facial nerve
Motor nucleus of
facial nerve
Superior
salivatory nucleus
Nucleus of tractus
solitarius
Nucleus of spinal
tract of the
trigeminal nerve
 1.Facial nerve nucleus[motor]
Location: deep in the reticular
formation of the caudal part of
pons,below and in front of abducent
nucleus
The motor nucleus represents SPECIAL
VISCERAL EFFERENT FIBERS( Branchial)
It presents the following nuclear sub-
groups
1. LATERAL
2. INTERMEDIATE
3. MEDIAL- a. Dorso-medial
b. Ventro-
medial
(BY-CARPENTER,1978)

Fibers from motor nucleus pass dorso-

medially towards the caudal end of the
abducent nucleus,and then run
rostrally superficial to that nucleus
occupying the FACIAL COLLICULUS of
the floor of FOURTH VENTRICLE.
At the cranial end of abducent nucleus
the fibers bend abruptly downwards
and forwards forming an INTERNAL
GENU and emerge from lower border of
 Other nuclei.
2.Superior salivatory nucleus: It lies dorsomedial to the facial
nucleus. It represents General Visceral Efferent Column. It gives
origin to preganglionic secreto-motor fibers which emerge
through sensory root

3.Nucleus of tractus solitarius: I t represents Special Visceral

Affrent column.primary terminal taste centre . fibres through
chorda tympani and from the soft palae through greater petrosal
nerve
.
4.Nucleus of spinal tract of the trigeminal nerve. It recieves
cutaneous sensations from the auricle through the auricular
branch of vagus nerve
 NEURONS
1- Upper motor neuron: Primary
motor cortex (Precentral gyrus)
The axons of these neurons enter
the Corticonuclear fiber bundle to
reach the second lower motor
neuron in the Pons.
2- Lower motor neuron: Facial
motor nucleus.
The facial nucleus is divided into
two parts:
The upper part receives bilateral
innervations, and supplies the
muscles of the forehead and
eyebrows (temporal branches).
The lower part receives
innervations mainly from the
contra lateral hemisphere, and
supplies the muscles of the lower
part of the face through the facial
nerve.
Central connections of the facial nerve

CROSBY AND DEJONGE, ALONG WITH NELSON, have provided two of

the most complete descriptions of the facial nerve's central
connections

Cerebral cortex: voluntary responses arise from pre & post central
gyri.

Corticobulbar tract: discharges from facial motor cerebral area are

carried through its fascicles to the internal capsule, thence through
upper midbrain & on to the pontine facial nucleus.
The tracts from upper face cross & recross en route to pons, while
those of lower face cross only once. descending corticofacial fibres
innervate LMN region bilaterally but with contralateral predominance,
whereas UMN receive scant direct cortical innervation on either side
of brain.
. In 1987, Jenny and Saper performed an extensive study of the
proximal facial nerve organizations in a primate model. 3They
demonstrated
UMN & LMN lesions and their clinical co-relation to corticobulbar
tract course & the regions of face affected.
 In 1987, Jenny and Saper performed an extensive study of the
proximal facial nerve organizations in a primate model.They
demonstrated that the descending corticofacial fibers
innervated the lower facial motor nuclear region bilaterally but
with contralateral predominance. The upper facial motor
nuclear regions received scant direct cortical innervation on
either side of the brain

Extrapyramidal system
The extrapyramidal system consists of the basal ganglia and
the descending motor projections other than the fibers of the
pyramidal or corticospinal tracts. This system is associated with
spontaneous, emotional, mimetic facial motions.
 Lower midbrain
A lesion in the lower midbrain above the level of the facial
nucleus may cause contralateral paresis of the face and
muscles of the extremities, ipsilateral abducens muscle
paresis (due to effects on the abducens nerve), and
ipsilateral internal strabismus . If the lesion extends far
enough laterally to include the emerging facial nerve fibers,
a peripheral type of ipsilateral facial paralysis might be
apparent.

Pons

The facial motor nucleus is located in the lower third of the

pons beneath the fourth ventricle. The neurons leaving the
nucleus pass around the abducens nucleus as they emerge
from the brain stem
SYNDROME LOCATION OF CHARACTERSTICS FEATURES
S LESION
Foville syndrome Lateral pons Ipsilateral facial paresis, ipsilateral facial
analgesia, ipsilateral Homer syndrome,
ipsilateral deafness

Meige syndrome Basal ganglion Facial dystonia

Millard-Gubler Pontine nucleus Unilateral sixth nerve palsy, ipsilateral seventh

syndrome nerve palsy, contralateral hemiparesis 4

Moebius Fundus of IAC to facial hiatus Ipsilateral facial paresis, ipsilateral abducens
syndrome (CN VI) palsy

Parkinson disease Extrapyramidal pathways Masked facies

Pseudobulbar Pontine Bilateral facial paresis with other CN defects,

palsy hyperactive gag reflex, hyperreflexia associated
with hypertension, emotional lability

Weber syndrome Upper midbrain Ipsilateral loss of direct and consensual pupillary
light reflexes, ipsilateral external strabismus,
oculomotor paresis
 Gangalia
Associated With
Facial Nerve
Ganglia related to facial
nerve.
Sphenopalatine
Submaxillary
Otic
Ciliary
 Sphenopalatine
ganglion.
Deeply placed in the
pterygopalatine fossa, close to
sphenoplatine foramen.

Triangular/heart shaped, reddish

gray in colour.

Sensory root: two

sphenopalatine branches of
maxillary nerve

Motor root: from nervus

intermedius,through greater
superficial petrosal nerve.
[sympathetic efferent,
preganglionic.].

Sympathetic root: derieved

from carotid plexus through
deep petrosal nerve.
Motor + symathetic root : nerve
of pterygoid canal.
 Submaxillary ganglion
Situated above the deep portion of the maxillary gland,
on the hyoglossus,, connected to & suspended from
lingual nerve, as a small fusiform ganglion.

Efferent preganglionic sympathetic fibres from superior

salivatory nucleus via chorda tympani nerve.

Post ganglionic fibres: to the submaxillary gland.

Communication: with the sympathetic plexus around the

external maxillary artery.

Branches of distribution: 5-6, from lower part of

ganglion, supplying the mucous membrane of mouth,duct
of submaxillary glands; via lingual nerve to the sublingual
gland.
 Otic ganglion
Small oval flattened structure lying just below the foramen ovale; medial to
mandibular nerve.

Relations: lateral mandibular n trunk.

medial-origin of tensor palatini muscle.
posterior- middle meningeal artery.

Branches of communication:
1. pterygoid internus n. [motor & sensory root. Q.]
2. glossopharyngeal & facial n. through lesser petrosal n. root from
glossopharyngeal, motor root from facial n.
3. sympathetic root from middle meningeal artery.
Preganglionic fibres from via glossopharyngeal from infr salivary/dorsal
nucleus.
Postganglionic with auriculotemporal n. to the parotid gland.
slender filaments to n. of pterygoid canal & chorda tympani.

Branches of distribution: tensor veli palatini, tensor tympani.

 Ciliary ganglion
Small, sympathetic, about a pinheads size.

Situated at the back of orbit, in loose fat b/w optic n. & rectus lateralis
muscle.

Roots:
sensory: from nasociliary n.
motor: from branch of oculomotor nerve
sympathetic: cavernous plexus

- Branches of communication from sphenopalatine ganglion.

Branches: short ciliary nerves to the ciliaris muscle, cornea and iris.
 Course anatomy- Facial nerve
segments:-
Intracranial segment:- supranuclear & brainstem parts.

Meatal segment:- [13-15mm] from brainstem to internal

acoustic meatus. Here nerve lies anterior & superior to VIII
cranial nerve components.

Intratemporal part:-
(a) Labyrinthine segment:- [3-4mm] narrow part from
fundus of IAC to facial hiatus. Common site of pathology,
temporal bone fracture etc.
(b) Tympanic segment:- [8-11mm] geniculate ganglion to
pyramidal turn.
(c) Mastoid segment:- [10-14mm] pyramidal process to
stylomastoid foramen.

Extracranial segment:- [15-20mm] stylomastoid foramen to pes

anserinus [goose foot].variable branching patterns on face.
 Intracranial course anatomy.
Sensory & motor roots.
Motor root:
< lies: deep in reticular formation of lower pons. above the nucleus ambiguus,
behind superior olivary nucleus, medial to nucleus of spinal tract of trigeminal
nerve.thence courses in the substance of pons.
< carries: somatic fibres to muscles of scalp, auricle,
buccinator,platysma,stapedius, stylohyoideus,posterior belly of digastric;
preganglionic sympathetic motor/vasodilator fibres to submaxillary & sublingual
glands.
< course: goes back & medially,reaches posterior end of abducent nucleus,then
runs up close to the midline beneath colliculus fasciculus,takes a second bend at
the antr end of abducent nucleus,then runs down & forward through pons to
emerge between the olive & inferior peduncle.

Sensory root:
[nervus intermedius/pars intermedii of wrisberg] arises from the genicular
ganglion.
Genicular ganglion: is situated on the geniculum of facial nerve in the facial
canal, behind the hiatus of the canal.
It has unipolar cells whose single processes divide in a T shaped manner into
central & peripheral branches.
1.central branches: leave the facial trunk in the internal acoustic meatus to
form the sensory root.
2.peripheral branches: continue into chorda tympani & greater superficial
petrosal nerve.
 Course segments of the facial nerve
(contd)

Meatal part: from their

superficial attachments to
the brain,the two roots of
the facial nerve pass lateral
& forward with the acoustic
nerve to the internal
acoustic meatus. In the
meatus, motor root lies in a
groove on the upper &
anterior surface of the
acoustic nerve, while the
sensory root lies in between.
[hence the name nervus
intermedius].
 Intratemporal part:
facial nerve enters the
facial canal at the bottom
of the meatus. It moves
laterally b/w the cochlea
& vestibule towards the
medial end of the
tympanic cavity,then
bends suddenly
backwards & arches
downwards, behind the
tympanic cavity, towards
the stylomastoid
foramen.(second genu).
 Extratemporal part: on
emerging from the
stylomastoid foramen,
facial nerve runs forward
in the substance of
parotid, crosses the ECA,
& divides behind the
ramus of mandible into
branches from which
offsets are distributed
over the side of face,
head, upper neck etc,
supplying the muscles of
this region. These
branches & offsets unite
to form the parotid plexus.
 Greater superficial petrosal
nerve
Arises from genicular
ganglion.
Consists of sensory
branches from mucous
membrane of soft palate &
few motor fibres to form the
motor root of
sphenopalatine ganglion.
Passes forward through
hiatus of facial canal.
Runs in a sulcus on anterior
surface of petrous temporal
bone beneath the semilunar
ganglion.
Moves to the foramen
lacerum, where it is joined
by deep petrosal nerve, to
form the nerve of pterygoid
canal which ends in
sphenopalatine ganglion.
Branches of distribution
In the facial canal: N. to stapedius
chorda tympani

At exit from SMF: posterior auricular

digastric
stylohyoid

On the face: temporal

zygomatic
buccal
mandibular
cervical
 Within facial canal.
N. of stapedius: arises opposite the
pyramidal eminence & passes through a
small canal in this eminence to reach
stapedius muscle.
Chorda tympani nerve:
Arises: from facial nerve as it passes down
behind the tympanic cavity, about 6mm
above SMF.
-Runs upward & forwards in a canal enters
tympanic cavity through an aperture on its
posterior wall [close to medial surface of
tympanic membrane, and on a level with
upper end of manubrium of the malleus].
-Transverses the tympanic cavity b/w fibrous
& mucous layers of the membrane.
Crosses the manubrium of the malleus.
-Emerges from tympanic cavity through a
foramen at the inner end of petrotympanic
-Receives a small branch from otic ganglion.
-Joins posterior border of lingual nerve at an
acute angle.
-Receives few efferents from motor root to
enter submaxillary ganglion.
-Majority of efferents from to mucous
membrane of anterior 2/3rd of tongue.
At exit from stylomastoid foramen:
Posterior auricular nerve: it arises near SMF to run upwards in
front of the mastoid process ,where it communicates with
1.auricular branch of vagus
2.posterior branch of greater auricular n.
3.lesser occipital n.

As it descends b/w external acoustic meatus & mastoid process, it

divides into
1.auricular branch: supplies auricularis posterior & internal muscles
on cranial surface of auricle.
2.occipital branch: larger, passes back along superior nuchal line of
occipital bone.supplies occipitalis.

Digastric branch: arises close to the SMF divides into filaments.

Supplies posterior belly of digastric muscle.One filament joins
glossopharyngeal nerve.

Stylohyoid branch: often arises in conjunction with digastric

branch.its long & slender, & enters stylohyoideus about its middle.
 Facial nerve-
on the face
Division at about 13mm
from SMF
Facial nerve lies in a
plane dividing the parotid
gland into its deep &
superficial lobes.
Two main divisions:
temporofacial &
cervicofacial
Supplies muscles of the
face.
5 main branches on the
face: temporal,
zygomatic, buccal,
mandibular, cervical.
 Temporal branches: crosses zygomatic arch into the temporal
Terminal
region. branches
>supply: auricularis antr & supr
>join: zygomaticotemporal branch of
maxillary,auriculotemporal
branch of mandibular.
>more antr branches supply: frontalis,
orbicularis oculi,corrugator.
>join: supraorbital & lacrimal br of opthalmic.
Zygomatic branches: run across zygomatic bone to lateral angle
of orbit
>supply: orbicularis oculi
>join: filaments from lacrimal branch of
opthalmic,zygomaticofacial br
maxillary n.
 Buccal branches: larger, pass horizontally forward to be distributed
below the orbit & around the mouth.
>superficial branches: run beneath the skin, above the superficial
muscles of face
which they supply.some to the procerus.
>deep branches: pass beneath the zygoma & quadratus labii
superioris.
supply: zygomaticus & quadratus labii superioris,small muscles of
nose.
form infraorbital plexus with the infraorbital nerve.
<lower deep branches: supply buccinator & orbicularis oris
join: filaments from buccinator br of mandibular n.

Mandibular branches: pass forward beneath platysma & triangularis.

supplies muscles of lower lip & chin.
communicates with mental br of inferior alveolar n.

Cervical branches: runs forward beneath platysma & supplies it.

forms a series of arches across side of neck in suprahyoid region.
one branch descends to join cervical cutaneous n. from cervical
plexus.
Branches of communication of the cranial
nerve VII.
In internal acoustic meatus: with acoustic nerve.
Genicular ganglion: 1.with sphenopalatine ganglion
via gr.superficial petrosal n.
2.with otic ganglion via a branch
joining lesser superficial petrosal n.
3.with the sympathetic plexus on the
middle meningeal artery via the
external petrosal nerve.
Within facial canal: auricular branch of vagus
Exit from SMF: 1.with glossopharyngeal n.
2.with vagus n.
3.greater auricular n. [of cervical plx].
4.auriculotemporal n .[in the parotid].
In the ear: with lesser occipital n. [behind the ear].
On face: with trigeminal n. branches.
In the neck: with the cutaneous cervical n.
 Realtion between facial nerve
and vestibulocochlear nerve from
brainstem to fundus of IAC

Variations in terminal
branching pattern
1. Buccal branches from the two main divisions of
facial trunk, not from other branches of facial
nerve.
2. Buccal branches arising from two main divisions
interconnected with zygomatic branch.
3. Marginal mandibular branch gives nerve twigs
to buccal branches.
4. Nerve twigs from zygomatics marginal
mandibular branches merge to buccal branch
arising from the two main divisions.
Surgical anatomy & landmarks.
Facial nerve at its exit from SMF: [surface anatomy] is situated
2.5cm from the surface, opposite the middle of the anterior border of
mastoid process, a horizontal line from this point to the ramus of
mandible overlies the stem of the nerve.

Localization of the facial nerve during parotid surgery:

1. Tragal pointer: points to main trunk proximal to Pes, 1-1.5 cm deep &
inferior to the pointer.
2. Tympanomastoid suture: traced medially, main trunk of VII lies 6-8mm
deep to suture line.[suture is 6-8mm lateral to SMF].
3. Posterior belly of digastric: guide to SMF. Trunk of VII lies just
posterior & superior to cephalic margin of the muscle.
4. Styloid process: sits 5-8mm deep to tympanomastoid suture, VII trunk
lies on its posterolateral aspect near its base.
5. Main trunk can also be found midway b/w,& 10mm posterior to, the
cartilaginous tragal pointer of external auditory canal & posterior belly of
digastric muscle.
6. Retrograde identification along a terminal branch.
Identification of terminal branches:
Buccal branch: runs with parotid duct superiorly or inferiorly. [Parotid
duct lies from lower margin of concha to midway b/w red margin of lip &
ala of nose, about a finger breadth below the zygomatic arch.

Temporal branch: crosses zygomatic arch parallel to superficial

temporal artery & vein. [superficial temporal artery can be followed
across posterior end of the zygomatic arch to a point 3-5cm above it,
where it divides into frontal & parietal branches.
Frontal branch: lies underneath frontalis, superficial to deep
temporal fascia,so dissect deep to subcutaneous plane/fascia.

Marginal mandibular branch: runs along the inferior border of parotid,

superficial to the retromandibular vein & lies along along the body of
mandible[or 1-2mm below in 20%cases]. It lies deep to platysma through
most of the course, but becomes superficial approx 2cm lateral to corner
of mouth, & ends on the undersurface of the muscle.
An injury results in paralysis of muscles depressing corner of the mouth
Diagnostic Test
Causes of facial nerve disorder vary from unknown to life threatening.
Sometimes, there is a specific treatment for the problem. Accordingly, it is
important to investigate why the problem has occurred. The specific tests
used for diagnosis will vary from patient to patient, but include:
Hearing tests:Hearing tests are done to assess the status of the auditory
nerve. The stapedial reflex test can evaluate the branch of the facial nerve
that supplies motor fibers to one of the muscles in the middle ear.
Balance tests:Will help find out if part of the auditory nerve is involved.

Tear tests:The loss of the ability to form tears may help to locate the site
and severity of a facial nerve lesion.
Taste tests:The loss of taste in the front of the tongue may help locate the site and
severity of a facial nerve lesion.

Salivation test:Decreased flow of saliva may help locate the site and severity of a
facial nerve lesion.
 Imaging studies:help determine if there is infection, atumor,
abone fracture, or any other abnormality. These studies are
usually aCT scanand/or aMRI scan.

Electrical tests:Stimulation of the nerve by an electrical current

tests whether the nerve can still cause muscles to contract. It can
be used to evaluate progression of the disease. For example, if
testing indicates equal muscle response on both sides of the face,
the patient can be expected to have complete return of facial
function in three to six weeks without significant deformity
Nerve injury-Sunderlands classification.
Class I- neuropraxia:
>pressure on nerve trunk, causing conduction block at pressure site.
>no disruption of axonal activity or connective elements.
>quick complete recovery on removal of pressure.
>stimulation of nerve distal to block can propagate impulses when no impulses can cross the
block.

Class II- axontemesis:

>more severe injury; wallerian degeneration of axon distal to injury,down to motor end plate.
>connective tissue elements intact, so nerve regenerates on removal of insult. delayed healing.
[1mm/day].

Class III- endoneurotmesis:

>severe lesion, disruption of axon & endoneurium, wallerian degeneration occurs.
>incomplete recovery on regeneration,because the axons regenerate into wrong/no
endoneurium.

Class IV- perineurotmesis:

>disruption of axon, endoneurium & perineurium.
>greater chance of abberant regeneration than in class III injury.

Class V- epineurotmesis:
>disruption of axon as well as connective tissue elements.
>no chance for regeneration unless transected ends are surgically re approximated.
House- Brackmann facial nerve grading
system.
Grade Description Characteristics
I Normal Normal facial function in all areas

II Mild dysfunction Slight weakness noticeable on

close inspection; may have very slight synkinesis

III Moderate Obvious, but not disfiguring, difference

dysfunction between 2 sides; noticeable, but not
severe, synkinesis, contracture, or
hemifacial spasm; complete eye
closure with effort

IV Moderately severe Obvious weakness or disfiguring asymmetry;

dysfunction normal symmetry and tone at rest;
incomplete eye closure

V Severe dysfunction Only barely perceptible motion; asymmetry at rest

VI Total paralysis No movement

Clinical & anatomic features of facial
nerve damage.
Facial paralysis
Etiology:

Idiopathic: bells palsy.

Traumatic: parotid tumours, facial n
schwannomas,acoustic neuromas, brainstem tumours.
Inflammatory: herpes zoster, lyme ds[borreliosis] ,
parotitis, otitis media, mastoiditis, EBV, poliomyelitis,
basilar meningitis, sarcoidosis, TB, coxsackie, mumps,
HIV, leprosy etc.
Congenital: Mobius synd, I/U trauma, perinatal
intracranial bleed.
Other suggested etiology:

Genetic [myotonic dystrophy],

Metabolic
[hypothyroid,hyperparathyroid,osteopetrosis,d
iabetes mellitus],
Vascular,
cleidocranial dysostosis,
melkerson rosenthal synd,
MS,
myasthenia gravis.
Causes of unilateral palsy: cerebellopontine
angle tumour, HZV,bells palsy, trauma, surgery
related, CULLP.contralateral with UMN lesion.

Causes of bilateral palsy: brainstem stroke,

contusion, glioma, myotonic dystrophy, mobius
synd, myasthenia gravis, guillain barre synd,
autoimmune demyelination, miller fischer synd,
melkersson rosenthal synd, sarcoidosis, lyme
disease.
Syndromes associated with facial paralysis.
Mobius syndrome: aplasia of VII nerve nuclei in brainstem [defect on
chromosome 3q], often accompanied by bilateral VI n. palsies, palatal
& lingual palsies, deafness, deficiency of pectoral & lingual muscles,
extremity defects.
Melkersson Rosenthal syndrome: recurrent facial palsy, orofacial
edema, fissured tongue.begins in teens. etiology unknown.
Ramsay Hunt syndrome: herpes zoster of VII, esp genicular
ganglion, presenting as unilateral VII palsy, severe otalgia, vescicular
eruptions on involved side.poorer prognosis.
Goldenhars synd: oculoauriculovertebral dysplasia. Defects of I & II
branchial arch structures. Anomalies include auricular deformities,
preauricular tags,EAC atresia, ossicular malformations, VII n.
hypoplasia, absent chorda tympani, colobomas, vertebral anomalies.
 Guillain Barre synd: autoimmune disorder causing acute
inflammatory demyelinating neuropathy..ascending motor
weakness with involvement of other cranial nerves,I,III,IV,VI.
Opthalmoplegia, paraesthesiae.
variants: 1.Miller Fischer syndrome.
2.chronic inflammatory demyelinating
neuropathy.

CULLP: congenital unilateral lower lip palsy.defect limited to

absent depressor labii inferioris activity.
Meihlke synd: thalidomide embryopathy. Microsomia, cr n VI,VII
involvement.
Heerfordt synd / Uveoparotid fever: form of sarcoidosis.
Bells palsy.
Definition: Acute, idiopathic, unilateral facial paresis or paralysis
in a pattern consistent with peripheral facial nerve dysfunction,
which maybe partial or complete; occuring with equal frequency on
the right & left sides of face.
Etiology: vascular causes, herpes viruses, inheritance.
Additional symptoms: otalgia, oropharyngeal/facial numbness,
impaired tolerance to ordinary noise levels, taste disturbances.
Prognosis: fair to good. signf improvement within 3 weeks to
months. full recovery in 70% cases.
Management: steroid therapy: p/o prednisolone 1mg/kg divided.
eyecare: tape shut, gold implants in eyelids,
patch, protective ointment & artificial
tears etc.
antiviral therapy for herpes infections.
Surgical management of facial
paralysis
Muscle transfer: masseter, temporalis.
Nerve cable grafting: greater auricular[10cm,in the region],
sural nerve[more fascicles,longer graft 40cm] grafts.
Direct nerve repair
Cross facial grafting
Facial hypoglossal anastomosis
Removal of other known etiology: tumours, trauma
management [temporal #] etc.
Mastoidectomy or middle cranial fossa decompression.
Other conditions assosciated with facial
nerve
Crocodile tears: gustolacrimal reflex. Patient with VII palsy who has affected
secretomotor fibres [tearing & salivation], may have tearing at mealtime due to
abberant fibre regeneration.
Spastic pareitic facial contracture: damage at nuclear/supranuclear level.
[causes: intrinsic pontine disease- stroke/ neoplasm/ MS, cerebellopontine angle
mass, bells palsy, Guillain barre synd.
Blepharospasm: bilateral episodic involuntary orbicularis oculi
contractions.sometimes assosc with lower facial musculature spasm, orofacial
dyskinesia etc.
etiol: essential, progressive supranuclear palsy, parkinsonism, MS, brainstem
stroke.
management: clonazepam, botulinum toxin [chemodenervation], selective nerve
sectioning, myectomies.
 Hemifacial spasm: usually unlateral, involving half of facial
muscle, typially lasting several mins at a time, present during
sleep.
etiol: post bells, abberant vascular loop compressing VII in
subarachnoid space where it exits pons.
treatment: carbamazepine/clonazepam etc.,
chemodenervation, surgical.
Facial myokymia: myokymia is spontaneous,fine fascicular
muscle contractions of muscle without muscular atrophy or
weakness.usually benign, self limiting. If persistent, consider MS,
brainstem glioma, stroke.
Jaw winking syndrome: a facial synkinesis, triggerd by jaw
opening, causing closure of the eyelids on the side of facial palsy.
[usually assosc with congenital facial palsy] .
References.
Anatomy of the human body Henry Gray.20th ed.
Sichers & DuBruls oral anatomy-8th ed
Clinical anatomy for medical students-Richard.S.Snell-6th ed
Cunninghams manual of practical anatomy vol.3.15ed.G.J.Romanes
Oral & maxillofacial surgery-the biomedical & clinical basis of surgical practice-vol1 Daniel.M.Laskin.
Textbook of oral & maxillofacial surgery-Gustav.O.Kruger
Contemprary oral & maxillofacial surgery-Peterson,Ellis,Hupp,Tucker
Principles of oral surgery-JR Moore,GV Gillbe
Burkets oral medicine-diagnosis & treatment
Textbook of oral pathology-Shafer,Hine,Levy
Concise Oxford textbook of medicine-Ledingham,Warrell
Harrisons principles of internal medicine
Davidsons principles of prctice of medicine
Neuroopthalmolgy review manual rev 5th ed.Amy Solomon.
Clinical signf of various anastomotic branches of facial nerve [katz,catalano & co] JAMA,otolaryng & head &
neck surg, vol113,no.9,sep 87.
Branching patterns of facial nerve [kwak & co]- J surg rediol anat 26[6], 494-500,dec 2004.
Bells palsy BMJ clinical evidence [online ed] julian holand
Bells palsy [DH Gilden]. New eng journal of medicine.vol351,no.13,1323-1331,sep 2004.
Bells palsy a case study.[domanico & co] IJANP issn 1528-6064.
Culled from the net- articles from e-medicine.com
Facial n anatomy- otolaryng article- patil & co,dept of otolaryng,george washington univ.[sep 06]
Congenital facial paralyis- lunstrom,allen & co,univ of colorado school of medicine.[jun 06]
Facial nerve intratemporal bone trauma- otolaryng article- massa,westerburg& co,univ of BC,canada.
Facial nerve repair- plastic & reconstructive surg article- byrne,hillge,univ of minnesota med school.
GR presentations[online ed],dept of otolaryng head neck surg,univ of texas- facial nerve paralysis-oct 94.
GR presntn[online ed] dept of otolaryng head neck surg, univ of texas- anatomy & physiology of the salivary
glands.