2,Facial Nerve Paralysis

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    Facial Nerve ParalysisFacial Nerve Paralysis

    Facial paralysis is a symptom & not aFacial paralysis is a symptom & not a

    diagnosisdiagnosis

    All that paralysis is not BellsAll that paralysis is not Bells

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    ANOTOMYANOTOMY

    Nucleus situated in PonsNucleus situated in Pons

    Ventral cell group innervates the lower facialVentral cell group innervates the lower facial

    musculature & Dorsal group the uppermusculature & Dorsal group the uppermusculaturemusculature

    UMN lesions forehead is sparedUMN lesions forehead is spared

    LMN lesions complete of the face isLMN lesions complete of the face isaffectedaffected

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    Meatal portionMeatal portion 88--10 mm Traverse IAM10 mm Traverse IAM

    along with 8along with 8thth N & Nervus IntermediusN & Nervus Intermedius

    Labyrinthine SegmentLabyrinthine Segment 4mm curves4mm curvesanteriorly around the basal turn of cochlea &anteriorly around the basal turn of cochlea &

    expands at Geniculate Ganglionexpands at Geniculate Ganglion

    Horizontal (tympanic segment)Horizontal (tympanic segment)

    11mm11mmGeniculate Ganglion to Level of HorizontalGeniculate Ganglion to Level of Horizontal

    semicircular canal, Turns 90 degreesemicircular canal, Turns 90 degree

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    Vertical (mastoid) portionVertical (mastoid) portion 13 mm HSCC to13 mm HSCC to

    Stylomastoid foramen (N stapedius &Stylomastoid foramen (N stapedius &

    Chorda tympani)Chorda tympani) In Parotid glandIn Parotid gland Temporal, Zygomatic,Temporal, Zygomatic,

    Buccal, Marginal mandibular & cervicalBuccal, Marginal mandibular & cervical

    branches supply all the muscles of facialbranches supply all the muscles of facial

    expressionexpression

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    AnatomyAnatomy

    IntracranialIntracranial

    MeatalMeatal

    LabyrinthineLabyrinthine

    TympanicTympanic

    MastoidMastoid

    ExtracranialExtracranial

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    Sunderlands classification of nerveSunderlands classification of nerve

    injuryinjury 11stst Degree: Conduction blockDegree: Conduction block

    22ndnd Degree: Transaction of axon with intactDegree: Transaction of axon with intact

    endoneuriumendoneurium 33rdrd degree: Transaction of nerve fiber indegree: Transaction of nerve fiber in

    intact perineuriumintact perineurium

    44thth

    Degree: Transaction of fasciculi withDegree: Transaction of fasciculi withintact epineuriumintact epineurium

    55thth Degree: Transaction of entire nerveDegree: Transaction of entire nerve

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    Neuropraxia:Neuropraxia:

    reversible conduction block (1reversible conduction block (1 damage).damage).

    Axonotmesis:Axonotmesis:loss of structural continuity of axon with intactloss of structural continuity of axon with intact

    endoneurial sheath (2endoneurial sheath (2damage).damage).

    Neurotmesis:Neurotmesis:33: loss of continuity of axons and endoneurial sheaths;: loss of continuity of axons and endoneurial sheaths;

    44: loss of continuity of axons, sheaths, funiculus;: loss of continuity of axons, sheaths, funiculus;55: complete loss of nerve continuity: complete loss of nerve continuity

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    CAUSESCAUSES

    A. Acute Paralysis:A. Acute Paralysis:

    1.1. Bells palsyBells palsy

    2.2. Herpes ZosterHerpes Zoster

    3.3. Autoimmune diseases e.g. Melkerson RosenthalAutoimmune diseases e.g. Melkerson Rosenthalsyndromesyndrome

    4.4. TraumaTrauma Skull fracture, Surgery ( Ear & parotid)Skull fracture, Surgery ( Ear & parotid), Penetrating injuries, Birth trauma, Penetrating injuries, Birth trauma

    5.5. Acute otitis media / CholesteatomaAcute otitis media / Cholesteatoma6.6. SarcoidosisSarcoidosis

    7.7. CVAsCVAs

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    B. Progressive / Chronic paralysisB. Progressive / Chronic paralysis

    Primary Parotid tumoursPrimary Parotid tumours

    1.1. Adenoid cystic carcinomaAdenoid cystic carcinoma2.2. Squamous cell carcinomaSquamous cell carcinoma

    3.3. High grade Mucoepidermoid carcinomaHigh grade Mucoepidermoid carcinoma

    4.4. Malignant Mixed tumourMalignant Mixed tumour

    5.5. Undifferentiated carcinomaUndifferentiated carcinoma

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    Metastatic malignanciesMetastatic malignancies

    1.1. BreastBreast

    2.2. LungLung3.3. KidneyKidney

    4.4. ColonColon

    5.5. SkinSkin

    Benign tumoursBenign tumours Schwannoma, Neurofibroma,Schwannoma, Neurofibroma,

    Hemangioma & Glomus tumourHemangioma & Glomus tumour

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    EvaluationEvaluation

    Physical examPhysical exam

    ImagingImaging

    ElectrophysiologyElectrophysiology

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    Neurodiagnostic TestsNeurodiagnostic Tests

    Topographic testsTopographic tests (site of lesion)(site of lesion)

    1.1. LacrimationLacrimation Schirmer testSchirmer test

    2.2. Salivary flow testSalivary flow test

    3.3. Taste testTaste test4.4. PTA (pure tone audiogram) & SpeechPTA (pure tone audiogram) & Speech

    discriminationdiscrimination

    5.5. Brain stem evoked response audiometryBrain stem evoked response audiometry

    6.6. Stapedial reflexesStapedial reflexes7.7. ENG (electroneurography)ENG (electroneurography)

    8.8. RadiologyRadiology CT Scan / MRICT Scan / MRI

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    Electrophysiologic Tests (prognostic)Electrophysiologic Tests (prognostic)

    1.1. Nerve excitability testNerve excitability test : both sides are compared ( MST ): both sides are compared ( MST )

    2.2. ElectromyographyElectromyography : After 2: After 2--3 wks fibrillation potentials3 wks fibrillation potentials

    Muscle degeneration. At later stage if recovery hasMuscle degeneration. At later stage if recovery hasbegunbegun Regeneration potentialsRegeneration potentials

    3.3. Evoked electromyography ( ENog)Evoked electromyography ( ENog) Latency is notedLatency is noted

    4.4. Strength duration curveStrength duration curve not widely usednot widely used

    Results of all tests should be correlatedResults of all tests should be correlated

    If testing indicates equal muscle response on both sidesIf testing indicates equal muscle response on both sides Recovery is expected in 3Recovery is expected in 3--6 weeks6 weeks

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    IMPORTANT CAUSES &IMPORTANT CAUSES &

    MANAGEMENTMANAGEMENT Bells PalsyBells Palsy: Acute 7: Acute 7thth N paralysis due toN paralysis due to

    viral inflammatory immune mechanismviral inflammatory immune mechanism

    1.1. Viral prodromeViral prodrome2.2. Pain around the earPain around the ear

    3.3. Facial numbness / EpiphoraFacial numbness / Epiphora

    4.4. Changes in tasteChanges in taste5.5. HyperacusisHyperacusis

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    TreatmentTreatment

    Steroids: 1 mg/Kg/day in divided doses &Steroids: 1 mg/Kg/day in divided doses &

    gradually tapered off in 15gradually tapered off in 15 21 days21 days

    Eye careEye care AntiviralAntiviral ? Acyclovir 200? Acyclovir 200--800 mg qid800 mg qid

    Facial nerve decompression: Usually notFacial nerve decompression: Usually not

    recommendedrecommended Physiotherapy: ControversialPhysiotherapy: Controversial

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    Herpes Zoster oticusHerpes Zoster oticus Ramsay HuntRamsay Huntsyndromesyndrome

    1.1. Viral prodromeViral prodrome

    2.2. Severe painSevere pain

    3.3. Vesicles around the pinnaVesicles around the pinna

    4.4. Recovery is less satisfactory as compared toRecovery is less satisfactory as compared toBells palsyBells palsy

    Treatment is same as Bells palsyTreatment is same as Bells palsy

    Acyclovir reduces post herpetic neuralgiaAcyclovir reduces post herpetic neuralgia

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    TraumaTrauma: Iatrogenic / Fracture Base of skull: Iatrogenic / Fracture Base of skull

    ImmediateImmediate Urgent surgical explorationUrgent surgical exploration

    DelayedDelayed ? Exploration is usually not? Exploration is usually notindicatedindicated

    In traumatic cases steroids may help toIn traumatic cases steroids may help to

    reduce recovery timereduce recovery time

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    AcuteAcute otitisotitis mediamedia: Toxic effect or: Toxic effect or

    mechanical compressionmechanical compression

    TreatmentTreatment1.1. AntibioticsAntibiotics

    2.2. MyringotomyMyringotomy

    3.3. CorticalCortical mastoidectomymastoidectomy/ Decompression/ Decompression4.4. SteroidsSteroids

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