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8/7/2019 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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