Page 1
Facial NerveDr. Dr. AbdulrahmanAbdulrahman HagrHagr MBBS MBBS FRCS(cFRCS(c))
Assistant Professor KingAssistant Professor King SaudSaud University University Otolaryngology ConsultantOtolaryngology Consultant
OtologistOtologist, , NeurotologistNeurotologist & Skull Base Surgeon& Skull Base SurgeonKing King AbdulazizAbdulaziz HospitalHospital
Page 2
Facial Nerve•• EmbryologyEmbryology• Anatomy• Physiology• Pathology
– Pathophysiology– Evaluation – Causes
• Treatment
Page 3
Embryology• Second Branchial Arch • 0.05 % unilateral facial palsy • 80% birth trauma • 90% spontaneous recovery • Congenital Unilateral Lower Lip Paralysis
(CULLP)• Anatomy of adult (Mastoid more superficial )
Page 4
Facial Nerve• Embryology
•• AnatomyAnatomy• Physiology• Pathology
– Pathophysiology– Evaluation – Causes
• Treatment
Page 6
Facial Nerve• 10,000 neurons• 7,000 myelinated facial expression.• Superiorly along the roof of the IAC (7UP)• The course 7segments
Page 7
Facial Nerve AnatomyFacial nerve segments:
1. Pons
2. Cerebulo-pontine angle (CPA)
3. Internal Auditory Canal (IAC)
4. Labyrinthine
5. Tympanic
6. Mastoid
7. External
Fallopian canal (FC)
Page 8
Pons4 Ss Nuclei1. Solitarius (Taste)2. Superior salivatory nucleus 3. Spinal nucleus of the trigeminal nerve4. Seventh motor
Page 11
Superior salivatory nucleus
Page 12
Motor part
• Precentral gyrus (frontal lobe)• Upper face corticobulbar
cross • Contralateral predominance• Motor fiber bend around the
abducens ( CN VIth) nucleus
Page 18
Fallopian canal• The labyrinthine segment
– shortest & narrowest part susceptible to compression – Only segment that lacks arterial anastomosis
• embolic phenomena• vascular compression
• Geniculate ganglion– 1st genu (bend or knee)– Common trunk (nervus intermedius and VII nerve)– Greater superficial petrosal nerve lacrimal gland
• Tympanic segment– 50% dehiscent – 1st 2nd genu
Page 19
Fallopian canal
• Mastoid segment– 2nd genu vertically stylomastoid foramen– longest part of the intratemporal course– Branchs
• Stapedius muscle• Chorda tympani nerve
submaxillary and sublingualTaste anterior 2/3 tongue pain, temperature, and touch EAC.
• Auricular nerve
Page 20
Extracranial
• Postauricular muscles• Stylohyoid muscle• Posterior belly of the digastric muscle • Pes anserinus (goose's foot ) separates
parotid deep and superficial lobes • 5 major branches T,Z,B,M,C• Highest risk during surgical T&M
Page 22
Pes anserinus (goose's foot )
Page 25
Facial Nerve• Embryology• Anatomy
•• PhysiologyPhysiology• Pathology
– Pathophysiology– Evaluation – Causes
• Treatment
Page 26
Physiology• Lacrimation• Expression• Mastication• Salivation• Speech• Hearing
Page 27
Facial Nerveتعرف في وجوه الذين آفروا (•
الحج ).. المنكر بالوجه خمسًا و خمسين عضلة •الوجه مرآة النفس و أن عليه •
تنعكس حاالت اإلنسان السيما العاطفية
Page 28
Facial Nerve• Embryology• Anatomy• Physiology• Pathology
––PathophysiologyPathophysiology– Evaluation – Causes
• Treatment
Page 29
Facial Nerve PalsyDegeneration• Metabolic source (cell body)
• Wallerian degeneration
• Begins within 24 hours
• Degeneration distal axon & myelin sheath
• Distal to the site of an injury
• Without local Inflammation
• Macrophages degrade myelin and axons
Page 30
Facial Nerve PalsyRegeneration• Axonal stumps swell and proliferating neurofilaments• Misdirected regrowth of nerve fibers
• Facial muscle contractures Synkinesia• Salivation crocodile tears
Page 31
Pathophysiology• Neuropraxia– no axonal discontinuity• Axonotmesis
– Wallerian degeneration (distal to lesion)– Endoneural sheaths intact
• Neurotmesis– Wallerian degeneration (distal to lesion)– Axon disrupted, loss of tubules, support cells
destroyed
Page 33
House-Brackmann• Grade 1
– = Neurapraxia– Spontaneous recovery
• Grade 2-3 – =Axonotmesis– Flow interruption – Wallerian anterograde degeneration. – Incomplete degeneration
Page 34
House-Brackmann• Grade 4
– =Neurotmesis ( permanent loss of axons)– Demyelinization– Moderate-to-severe facial musculature
dysfunction– Regenerative synkinetic movements
• Grade 5 and 6– Partial or complete transection of the nerve– Minimal/complete loss of function
Page 35
Facial Nerve• Embryology• Anatomy• Physiology• Pathology
– Pathophysiology
––EvaluationEvaluation– Causes
• Treatment
Page 36
Evaluation• Careful history • Physical exam• Audiometry• CT/MRI/other• Topographic• Electrophysiology
Page 37
History• Timing• Associated symptoms • SNHL• Vesicles• Severe pain• Trauma• OM acute or chronic• Past medical history
Page 38
Physical exam• Complete head and neck exam
• Wide smile • Whistling • Blowing
• LMNL– Forehead wrinkling– Eye closure– Bell’s phenomenon
Page 40
Topognostic Tests• Schirmer’s Test• Stapedial reflex• Taste• Salivary Flow• Imaging
Page 42
Evaluation Facial Nerve PalsyElectro-Physiology• Electroneurography (ENoG)
• Electromyography (EMG)
• Nerve excitability test (NET)
• Maximum stimulation test (MST)
ACUTE=Acute+Complete+Unilateral+Threedays Evaluate
Page 45
Facial Nerve• Embryology• Anatomy• Physiology• Pathology
– Pathophysiology– Evaluation
––CausesCauses• Treatment
Page 46
Facial Nerve Palsy
Causes:• Congenital
• Trauma
• Iatrogenic
• Idiopathic
• Infection
• Toxic
• Neurologic
• Neoplastic
Page 47
Facial Nerve PalsyTrauma• Forceps delivery
• Basal skull/temporal bone fractures
• Facial injury
• Penetrating to middle ear
• Barotrauma
• Lightning
Page 51
Case Case LEFT EAR (AS)
250 500 1000 2000 4000 8000
100
0
10
20
30
40
50
60
70
80
90
110
1
1
NR IPSI & CONTRA
Page 52
Fractures• Longitudinal
– 80% of Temporal Bone Fractures– 15-20% Facial Nerve involvement
• Transverse– 20% of Temporal Bone Fractures– 50% Facial Nerve Involvement
Page 55
Facial Nerve Palsy
Iatrogenic• Parotid surgery
• Mastoid surgery
• local anesthesia
• Acoustic neuroma
Page 56
االحصاءات الصادرة عن وزارة الصحة
2005 ـ 2004عام • على اللجان الطبية الشرعية عرضت قضية 896• قضية منها428صدرت قرارات إدانة في • طبيبا مدعى عليهم848 طبيبا من اصل 299إدانة •من عدد القضايا المنظورة % 35 •
10120 العدد 2006 اغسطس 13 هـ 1427 رجـب 19االحـد الشرق االوسط
Page 57
Iatrogenic Facial Nerve Palsy
Page 58
Iatrogenic Facial Nerve Palsy
Page 59
Facial Nerve PalsyIdiopathic• Bell’s
• Melkersson-Rosenthal
• Guillian-Barre
• MS
• Myasthenia gravis
• Sarcoidosis (Heerfordt’s)
Page 60
Bell's Palsy• Commonest cause of acute VII paralysis• Diagnosis of exclusion• Unilateral facial paralysis • Sudden onset • Unknown cause• LMNL
Page 61
Bell's Palsy• Limited duration• Minimal symptoms• Spontaneous recovery• No sensory loss
Page 62
Bell's Palsy? Immune or viral Swelling of the nerve
Compression and ischemiaComplete paralysis
Page 63
Diagnosis• Weakness of the entire half of the face • In doubt CT and MRI scans • MRI may show contrast enhancement
of the facial nerve
Page 64
Prognosis and Treatment• Complete recovery
– 90% Complete recovery– Several months
• Prevent corneal drying– Natural tears– Isotonic saline – Strips of skin tape to close the eye
Page 65
Medical Management• Corticosteroids
– 80 mg/day po– Within 24 to 48 h of onset for 1 wk– Decreased gradually over the 2nd wk
• Antivirals (Acyclovir )– Less degrees of facial weakness
Page 66
Melkersson-Rosenthal
4 Fs• Facial nerve palsy
(Recurrent )
• Furrowed tongue
• Faciolabial edema
• FHx + ve
Page 67
Melkersson-Rosenthal
Page 68
Sarcoidosis (Heerfordt’s)
Page 69
Facial Nerve PalsyInfection• Malignant otitis externa
• Otitis media
• Mastoiditis
• Ramsey Hunt (Herpes zoster)
• Encephalitis
• Polio
• Syphilis
Page 70
Malignant Otitis Externa
4 Ds• Diabetes mellitus • Discharge (Purulent )• Discomfort• Dysfunction Cranial nerve
• Granulation obscured TM
Page 72
Ventilating Tubes
Page 74
Ramsay Hunt• Herpetiform vesicular
eruptions (VZV)• Painful• vestibulocochlear
dysfunction• Treatment is equivalent to
Bell palsy• Poor outcome
Page 75
Facial Nerve PalsyNeoplastic• Malignant parotid lesion
• Cholesteatoma
• Acoustic neuroma
• CN VII tumor
• Meningioma
Page 76
NeoplasticSPORT Neoplasm• Slowly progressive• Persistent >4 months• Other C.N. Ex SNHL • Recurrent• Tumor History
Page 79
Neoplastic Facial Nerve Palsy
Acoustic neuroma
Page 80
Facial Nerve• Embryology• Anatomy• Physiology• Pathology
– Pathophysiology– Evaluation – Causes
•• TreatmentTreatment
Page 81
Facial Nerve PalsyFunctional deficits• Lagopthalmos and ectropion
• Oral incompetence
• Nasal obstruction
• Mastication difficulties
• Articulation difficulties
Often severe psychological distress
Page 82
Goals of restoration• Corneal protection
• Facial symmetry at rest
• Symmetric smile
• Oral competence
Page 83
Facial Nerve PalsyDynamic Reanimation1. Primary repair2. Interposition nerve grafts3. Crossover reinnervation procedures
Ansahypoglossi Hypoglossal& Cross-facial
4. Regional muscle transferTemporalis, Masseter & Digastric
5. Microneurovascular free-flapGracilis, Latissimus dorsi & Rectus abdominis
Page 84
Facial Nerve PalsyStatic Reanimation• Brow and forehead lift• Eyelid procedures
Gold weight, Spring & Lower lid tightening
• Correction of midfacial deformityFascia lata, Alloplastic sheets & Facelift
• Lower lip wedge resection• Botulinum toxin
Page 85
Restore Neural inputPrimary nerve repair
- Preformed immediately- Small gap (<17mm)- Epineural or perineural- Magnification- No tension- Best outcome- Expect HB III
Page 86
Restore Neural input
Interposition graft
- HB III
- Variable synkinesis
- Improvement over 6 to 18 months
Page 87
Hypoglossal-facial crossover
Page 88
Muscle transposition
Masseter transfer
Page 89
Muscle transposition
Temporalis transfer
Page 90
Temporalis Muscle transposition
Page 91
Non-functional facial musclesFree gracilis
Page 92
Non-functional facial muscles
Free gracilis trigeminal innervation
Page 93
Static reanimation
Page 94
Botulinum Toxin• Synkinesis and hypertonia• Advantages
• Ease of use• Selective
•Disadvantages• Temporary• Repeated every 3 months
Page 95
Conclusions• Facial paralysis sequlae (significant)
• Functional• Cosmetic • Psychological
• The primary goals of facial reanimation• Corneal protection• Symmetry at rest • Smile restoration
Page 96
ConclusionsPrimary repair
Cable rafting
CN XII-CN VII anastamosis
Static Reanimation
Microneurovascular
Hyperkinetic Botulinum toxin
Page 97
Facial Nerve• Embryology• Anatomy• Physiology• Pathology
– Pathophysiology– Evaluation – Causes
• Treatment