Facial nerve presentation by Dr Salison Salim Panicker.pptx

Facial nerve Presentation by Dr Salison Salim { RelentCare Ent center Thrissur} , facial nerve development, course, anatomy ,injuries, complications, treatments, reanimation techniques everything presented in a concise manner

1. FACIAL NERVE & ITS DISORDERS MODERATOR : DR GITANJALI PRESENTER : DR SALISON SALIM PANICKER

2. FACIAL NERVE 7th cranial nerve Nerve of second branchial arch MIXED – MOTOR+PARASYMP+SENSORY{NERVUS INTERMEDIUS}

3. EMBRYOLOGY Developmentally derived from 2 nd branchial arch 3 rd week of gestation from Facio -acoustic primordium along with vestibulocochear n. facial part terminates on the upper portion of 2 nd branchial arch after forming neurons of main trunk, geniculate ganglion and chorda tympani. facial motor nucleus arises from pontine part of metencephalon .

4. The sensory root ( Nervus Intermedius ) arises from geniculate ganglion and passes proximally to the brain stem between motor root and VIIIth cranial nerve. The intra temporal segment of facial nerve forms before the extratemporal segment fusion occurs only post partum near the oval window.

5. CLINICAL SIGNIFICANCE Ritchers cartilage forms thebones of 2 nd pharyngeal arch Congenital anomalies of external and middle ear- facial nerve anomaly should be anticipated. Mobeius syndrome- close relationship of 6&7 nerves during development Incomplete closure of the otic capsule sulcus can cause dehiscence of the fallopian canal - most common congenital malformation of temporal bone.

6. At birth the mastoid process is absent and the tympanic ring narrow; hence the facial nerve is just beneath the skin at the stylomastoid foramen and hence quite vulnerable to injury Post aural incision should be more horizontal.

7. ANATOMY &FUNCTIONS MOTOR ROOT {7000 FIBRES} MIXED NERVE SENSORY ROOT(NERVE OF WRISBERG) {3000 FIBRES}

8. NERVUS INTERMEDIUS Named from its position between the facial nerve and the vestibulocochlear nerves at the brain stem Nervus intermedius ( Nerve of Wrisberg ): sensory and para sympathetic fibres General visceral efferent fibres from superior salivatory nuclues -> submandibular, sublingual, minor salivory , nasal and lacrimal glands

9. Special visceral afferent fibres - > taste to the anterior 2/3 rd of tongue& palate>> nucleus of tractus solitarius . Somatic afferent fibres - > innervation to the skin of concha, posterosuperior part of external auditory canal , & retroauricular skin.

10. MOTOR ROOT Special visceral efferent: forms motor root Supplies all muscles of facial expression, auricular muscles,buccinator , platysma , stylohyoid , posterior belly of digastric , & stapedius .

11. Course And Branches Of Facial Nerve

12. NUCLEUS OF FACIAL NERVE Motor nucleus : situated in pons . Recieves fibres from precentral gyrus . Upper part of nucleus recieves fibres from both part of hemispheres. It innervates forehead muscles . Lower part of nucleus gets crossed fibres from hemisphere.Supplies lower face. Thus function of forehead preserved in supranuclear lesion.

13. Also recieves fibres from thalamus and provides involuntary control to facial muscles. So emotional movements are preserved in supranuclear palsies.

14. 2 other nuclei contributing to the facial nerve superior salivatory nucleus supplying secretomotor parasympathetic fibers and nucleus of tractus solitarius supplying taste fibers

15. FACIAL COLLICULUS Fibres from facial nerve nucleus travel posteromedially and then wind around the 6 th nerve nucleus- internal genu Visible as a bulge in the floor of 4 th ventricle Runs ventrolaterally b/w lateral superior olivary nucleus and descending trigeminal root.

16. INTRACRANIAL PART The motor root emerges at the lower border of ventral surface of pons accompanied by the sensory root anteromedial to the vestibulocochlear nerve and enters the cerebellopontine ( pontomedullary cistern) angle. Cisternal portion – 24 mm long, The three nerves run rostrolaterally through the CP angle into the petrous part of temporal bone entering the internal auditory meatus accompanied by the labyrinthine vessels . The nerves are ensheathed by a delicate layer of arachnoid mater , so difficult to identify in shwanomma

17. INTRATEMPORAL part of facial nerve Internal auditory meatus to stylomastoid foramen -28-30mm Meatal segment : within IAM. porus to fundus [5-12 mm] . Labrinthine segment : (3-5mm) fundus to geniculate ganglion-shortest Tympanic segment : from geniculate ganglion to pyramidal eminence-above the oval window and below the lateral SCC Mastoid or vertical segment : pyramid to stylomastoid foramen

18. These proximal segments are invested by arachnoid mater but lack epineurial and perineurial sheaths rendering suturing technically challenging if not CI in favour of glue

19. MEATAL SEGMENT Between the porus to the fundus about 5-12 mm long . At the fundus the internal auditory canal is divided into superior and inferior compartments by the falciform crest (crista falciformis ) , facial nerve passes superior to the Cochlear part of VIIIth nerve and is posteriorly separated from the superior vestibular nerve by a vertical bony ridge named the Bill’s bar. Nervus intermedius joins facial nerve within IAM , 3mm from porus BILL IS WILLIAM HOUSE – THE FATHER OF NEUROOTOLOGY-[DEVELOPED COCHLEAR IMPLANT]

20. FALLOPIAN CANAL Bony canal in temporal bone. 28-30mm long From porus to stylomastoid foramen Course of facial nerve: 3parts

21. LABRYNTHINE SEGMENT [3-5 mm] l 0.68mm diameter Only segment with no anastomosis arterial cascades and is vulnerable to embolic phenomenon, low flow states and vascular compression Most affected part due to odema on inflammation or trauma Narrowest part and shortest part At GG , FN is cradled by sup SCC post and cochlea ant inf

22. GENICULATE GANGLION Sensory ganglion with no synapses Central process of the GSA neurons in geniculate ganglion carry pain from EAM and terminate somatropically in spinal nucleus V Central process of SVA , carry taste fibres to 2 nd neuron in NTS {via CT} Distal end - labrinthine segment facial N - acute posterior turn to form the first genu( external genu) Gives 1 st branch: greater superficial petrosal nerve

23. PREGANGLIONIC PARASYMPETHTEIC FIBRES DESTINED FOR PPG AND SUBMANDIBUALR GANGLIA PASS THROUH GG , WITHUT SYNAPSE GG – in fossa sep from MCF by thin bone DEHISCENCE RENDER VULNERABLE TO INJURY IN MCF

24. GENICULATE NEURALGIA Otic dolourex of NI PAIN FELT DEEP IN EAR ZOSTER ZONE VASCULAR LOOPS AND PREV HZ INFECTION GENICULATE GANGLIONECTOMY AND NI SECTION

25. TYMPANIC SEGMENT Tympanic segment: 8-11mm From the geniculate ganglion to the pyramidal eminence The facial nerve runs on medial wall of the tympanic cavity, above and posterior to the oval window below the horizontal semicircular canal. MC SITE OF FN DEHISCENSE

26. MASTOID SEGMENT Mastoid segment: facial nerve emerges from the middle ear distal to the pyramidal eminence, making a second turn (second genu) downwards between the posterior wall of the external auditory canal and the horizontal semicircular canal Mastoid segment : 2 nd genu to stylomastoid foramen Landmark :ant end of Digastric ridge Longest intratemporal part: 10-14mm

27. 2 branches Nerve to stapedius Chorda tympani

28. Facial nerve is surrounded by thick fibrous tissue at stylomastoid foramen , attached to the fibrous tendon of digastric muscle Surgical release of the nerve require dissection en bloc with post belly of digastric and bone around foramen

29. Facial nerve exits the skull via stylomastoid foramen It runs between the digastric and stylohyoid muscles and gives off smaller rami before dividing into terminal branches Post auricular nerve{ occipital; belly of occipital frontalis, auricularis superior and intrinsic auricular muscles] Nerve to post belly of digastric Nerve to stylohyoid Then crosses lateral to the styloid process and enters the parotid gland to divide into the terminal branches.

30. BRANCHES GREATER SUPERFICIAL PETROSAL NERVE: 1 st branch; from the geniculate ganglion enters the middle cranial fossa and pterygoid canal where it joins the deep petrosal nerve to form the Vidian nerve (nerve of pterygoid canal). parasympathetic axons in this nerve synapse in the pterygopalatine ganglion

31. postganglionic parasympathetic fibers >>maxillary division of the trigeminal nerve, >> secretomotor supply to lacrimal, nasal and palatal glands also taste from the palate.

32. NERVE TO STAPEDIUS from the proximal part of mastoid segment To the stapedius muscle Acoustic stapedial reflex for protection of inner ear in response to loud sounds

33. CHORDA TYMPANI about 4 – 6 mm proximal to the stylomastid foramen; exits the mastoid bone through posterior canaliculus just deep to the tympanic annulus, runs anteriorly upwards in the middle ear between the incus and neck of malleus along the medial aspect of the TM

34. Exits tympanic cavity - petrotympanic fissure ( canal of Huguier ) - join the lingual nerve. FUNCTIONS Carries preganglionic parasympathetic secretomotor fibers to SUBMANDIBULAR GANGLION - submandibular and sublingual salivary glands afferent taste fibers from the anterior two-third of the tongue.

35. EXTRACRANIAL BRANCHES POSTERIOR AURICULAR NERVE : Muscles of auricle and occipitalis muscle. 2 small branches : Nerve to post.belly of digastric & stylohyoid Within parotid: 2 major divisions Temporofacial (sup)and cervicofacial(inf) 5 terminal branches: pes anserinus

36. PES ANSERINUS Supply muscles of facial expression Temporal Zygomatic Buccal Marginal mandibular Cervical

37. Temporal branch >>forehead muscles and the superior part of the orbicularis oculi. Zygomatic branch >>muscles of the nasolabial fold. Buccal branc h>> buccinator and rest of orbicularis oculi. Marginal mandibular branch >>muscles of lower lip and chin C ervical branch >> platysma muscle

38. BLOOD SUPPLY Intracranial – Anterior inferior cerebellar artery Intratemporal – Labyrinthine branch of Anterior inferior cerebellar artery, Petrosal branch of middle meningeal artery and Stylomastoid branch of Posterior auricular artery Extratemporal – Stylomastoid branch of post.auricular artery, Occipital artery and transverse facial branch of superficial temporal artery

39. BLOOD SUPPLY VERTIBROBASILAR AND ECA SYSTEM CP ANGLE – AICA Labrynthine artery –from aica - supply- Meatal , labrynthine GG and adjacent facial nerve by superficial petrosal nerve Mastoid and tympanic segment by facial arch {superficial petrosal branch of mma and stylomastoid artery branch F post auricular artery Stylomastoid artery supply chorda tympani Post auricular and occipital artery supply FN from stylomastoid foramen to parotid Superficial temporal , facial , maxillary artery supply the pes anserius

40. SURGICAL LANDMARKS For middle ear & mastoid surgery: Processus cochleariformis : landmark for1ST GENU- geniculate ganglion , which lies anterior to it. Oval window & horizontal canal : facial nerve runs-[SECOND GENU] above oval window & below [ infero lateral] horizontal canal. .

41. the nerve is located medial and inferior to the short process of incus within the fossa incudis Facial nerve is 6-8 mm deep to and behind the tympanomastoid suture It runs in a line to the anterior extent of digastric ridge which points to the stylomastoid foramen

42. For parotid surgery Landmarks - include the Facial nerve runs posterolateral to styloid process at its base Tragal pointer [CARTILAGENOUS POINTER OF CONLEY] - 1cm medial and inferior Tympanomastoid suture line- 6-8 mm below It can also be located about 1cm deep to the medial attatchment of the posterior belly of digastric muscle on the digastric groove of mastoid RETROGRADE DISSECTION – retromandibular vein is commonly used landmark for marginal mandibular nerve[ also following facial vein]

43. Applied anatomy UMN vs LMN LESIONS: pontaine motor nucleus: Upper and lower half >> upper and lower halves of face Upper half- innervation from both corticobulbar tracts Upper facial movements preserved during UMN lesions LMN Lesions: both halves are affected

44. Emotional facial expressions : Supranuclear lesions preserve involuntary emotional movements of the face connected to the motor nucleus via alternate routes arising from the thalamus and globus pallidus

45. FACIAL PALSY Patients with any form of facial nerve abnormality should be evaluated to rule out non-neurologic disease ;their facial dysfunction can be treated much effectively

46. SEVERITY OF NERVE INJURY Degree of nerve injury-Regeneration and recovery depends on the degree of nerve injury. Earlier it was classified as Seddon‘s Neuropraxia : Conduction block. Flow of axoplasm through axons are partially obstructed. Axonotemesis : injury to axons , wallerian degen occurs , initial sing of recovery in 3 month Neurotemesis : injury to nerve. Injury to endoneurium or myelin sheath as axon regenerates free to find any distal endoneural tube of another axon- walletian degenration occurs :- surgical intv needed

47. Sunderlands classification 1 st degree ( Neurapraxia ) Only flow of axoplasm through axon obstructed; no degeneration. Recovery complete 2 nd degree ( Axonotmesis ) Injury to axons with wallerian degeneration distal to lesion; endoneurium intact. Regeneration of axon & recovery complete 3 rd degree ( Neurotmesis ) Injury to axon and endoneurium; regeneration unpredictable. Usually residual dysfunction, aberrant regeneration & synkinesis 4 th degree Injury to perineurium; partial nerve transection. Scarring prevents effective regeneration 5 th degree Complete nerve transection with injury to epineurium as well.

48. HOUSE-BRACKMANN STAGING SYSTEM

49. DRAWBACKS 1. Inter observer variability 2. Applicable only to lesions proximal to pes anserinus 3. Not useful in single branch injury

50. Sequels and complications Ocular complications : Lagophthalmos & corneal exposure Keratitis Corneal ulceration& opacification Epiphora Synkinesis : abnormal synchronization of movements due to activity of muscles that normally don’t contract together

51. SYNKINESIS. ---- abnormal synchronization of movements due to activity of muscles that normally don’t contract together due to faulty remyelination with nerve regeneration. After injury DYSGEUSIA HYPERACUSIS PAIN Crocodile tears (Gustatory tearing) : increased lacrimation during meals aberrant regeneration of the parasympathetic nerves- postganglionic parasympathetic fibres to the salivary glands innervate the lacrimal glands

52. sectioning of the greater superficial petrosal nerve in troublesome cases. Hemifacial spasm – Hyperkinetic disorder which starts as mild intermittent spasm of the orbicularis oculi muscle but increase in severity to involve the all muscles of facial expression on one half of face vascular compression of the nerve at the brainstem

53. Facial myokimia :Fine continuous fibrillary movements of facial muscles resulting in a ‘bag of worms’ appearance of the face degenerative diseases like multiple sclerosis or in brainstem tumors. Stapedius muscle contraction:  Hyperkinetic disorder due to faulty regeneration causing inadvertent contractions presenting as aural fullness and tinnitus Sectioning of the stapedius tendon via a tympanotomy

54. Evaluation of a case of 7 th nerve palsy HISTORY: Onset: sudden/delayed Progression u/l or b/l Extent: complete/incomplete; diffuse/segmental Facial palsy in the past Asso . Symptoms:aural symptoms, facial vesicles, CNS symptoms. Medical history h/o trauma

55. Previous surgery Family history CLINICAL EXAMINATION : Resting symmetry of face. Abnormality in movements Examination of eye Examination of ear Taste sensation Neurological examination

56. Level of lesions and manifestations Lesion Manifestatio n SUPRANUCLEAR C/L hemiplegia , Dec jaw jerk NUCLEAR I/L 6 , 7, c/l hemiplegia C.P ANGLE I/L 5,7,8 palsy SUPRA GENICULATE Dec lacrimation ,hyperacusis, loss of taste SUPRA- STAPEDIAL Hyperacusis, loss of taste SUPRA-CHORDAL loss of taste INFRA-CHORDAL Facial assymetry only

57. INVESTIGATIONS Audiovestibulometry : Close proximity of vestibulocochlear nerve to 7 th nerve during its course in the temporal bone Conductive and sensory neural hearing loss Conductive: middle ear lesions SNHL: lesions in CP angle and internal auditory canal

58. Topodiagnostic tesing Topognostic tests effectively locate the site of lesion within the temporal bone in patients with facial palsy Lesions distal to the site of a particular branch of the facial nerve will spare the function of that branch.

59. Schirmer’s test Sterile filter paper strips (5 x 35 mm) are placed into the lower conjunctival fornix the junction of middle and outer third rate of tear production is compared. A reduction > 75 DEGREE unilateral loss of lacrimation on affected side or less than 10 mm wetting billaterally over 5 minutes is significant Lesion involving grtr sup petrosal nerve/ proximal to geniculate ganglion At risk of exposure keratitis

60. Acoustic Stapedial reflex measures bilateral contraction of stapedius muscle in response to loud sounds. Absence of the reflex when either ear is stimulated with normal VIII nerve function suggests an abnormality of the facial afferent . Most objective and reproducible

61. Taste Chorda tympani Routine clinical examination Electrogustometry : The tongue is stimulated electrically to produce a metallic taste and the two sides are compared Threshold of the test is compared between sides

62. Salivary flow This involves cannulation of Wharton's ducts bilaterally with measurement of output after five minutes. A 25% reduction in flow of the involved side as compared to the normal side is considered significant Warthin’s ducts are cannulated and salivary flow is measured over time following a gustatory stimulus (6% citric acid on anterior part of tongue)

63. Salivary pH As the rate of salivary flow increases, the pH increases. Therefore, a pH of less than 6.1 may predict loss of function of the chorda tympani. 

64. Electrophysiologic Tests To evaluate the degree of dysfunction& potential of recovery Used in patients with complete paralysis to aid in facial reanimation procedures { NOT IN INCOMPLETE PARESIS} useful before deciding on facial nerve decompression surgery can only be used for unilateral paralysis because valid results involve comparison to the contralateral side which must be normal Minimum after 3 days , no use in 72 hrs No useful information i8n incomplete paralysis Tests NET MST ENoG EMG TRANSCRANIAL MAG STIMULATION

65. CLASSICAL TESTS Normal bedside test using a hilger stimulator NET –nerve excitability test Minimum current needed transcutaneously to provoke a muscle movement MST – maximum stimulation test Current required for maximum response without causing discomfort for the patient Disadvantage- accuracy , reproducibility , prognostic value , interobserver variation

66. Electroneuronography ( ENoG ) EVOKED ELECTROMYOGRAPHY CMAP – COMPUND MUCLE ACTION POTENTIAL MEASURED WITH SURFACE ELECTRODE COMPARED TO NORMAL SIDE DONE ONLY AFTER 4 DAYS most accurate and valuiable prognostic test because it provides an objective and qualitative measurement of neural degeneration Main indication is acute onset complete facial nerve paralysis facial nerve is stimulated transcutaneously at the stylomastoid foramen and muscular response: compound muscle action potential (CMAP) picked bipolar electrodes placed near the nasolabial groove this would be proportional to the number of intact axons

67. INTRERPRET ENoG Traumatic injury with >90 percent fall in amplitude go for surgery Response compared with normal side & percentage of degeneration calculated. >90% loss suggest poor prognosis Measured during 4 th day-3weeks

68. ELECTROMYOGRAPHY Tests the motor activity of facial muscles(orbicularis oris & orbicularis oculi) by direct insertion of electrodes &recordings made during rest & voluntary activity Normal resting muscle - bi or triphasic potential is seen every 30- 50 ms . Denervated muscle : Involuntary spontaneous action potential (fibrillation potential) - appear 14-21 days after injury [ Wallerian degeneration of lower motor neuron, but viable motor end plate-> surgical exploration is indicated]

69. Regeneration: polyphasic rei-innervation potential appear 6-12 weeks prior to clinical evidence of facial function SILENCE :If no motor endplate detected by EMG – FN repair is contraindicated Use free muscl transfer nusc ,facial reanimation

70. TRANSCRANIAL MAGNETIC STIMULATION FACIAL NERVE WITHIN THE CRANIUM MAGNETIC IMPULSE USING COILS TO STUDY PALSIES

71. BLOOD INVESTIGATION CBC, RBS,TSH ANGIOTENSIN CONVERTING ENZYME TITRE- SARCOIDOSIS {HEERFORDTS SYNDROME} ANCA – GRANULOMATOSIS WITH POLY ANGITIS HIV LYME – ELISA ,WESTERN BLOT, PCR {BORELLIA BURGDORFEI ] SYPHILIS –VDRL, FTA-ABS DO SOONER THAN LATER

72. IMAGING IN FACIAL NERVE PALSY INDICATIONS Associated with signs of CNS involvement Associated parotid swelling Following trauma Ear infection suggestive of Cholesteatoma Progressing beyond 3 weeks Not recovering even after 6 months Recurrence on the same side

73. HRCT 0.6 MM CUT TO 0.3 MM is indicated predominantly in traumatic lesions of facial nerve like temporal bone fractures and in middle ear cholesteatoma CONE BEAM CT –LESS RADIATION WITH MUCH NARROW CUTS 0.05MM MRI WITH GADOLINIUM CONTRAST would be better in inflammatory and neoplastic lesions like cerebellopontine angle lesions and facial nerve schwannoma

74. SPECIFIC CONDITIONS Bilateral facial palsy Bilateral facial nerve palsy is rare comprising of only 0.3- 2% of all cases of facial nerve paralysis; may be seen in the following situations Guillain-Barre syndrome Sarcoidosis Infectious mononucleosis. Lyme disease Leprosy

75. Skull base fractures Cerebro vascular accidents Meningitis Brain stem encephalitis Leukemia Melkerson Rosenthal syndrome Moebius syndrome Acute porphyria Botulism

76. Should be differentiated from other causes of facial weakness. as seen in myotonic dystrophy, Parkinsonism or myasthenia gravis.

77. Recurrent facial palsy Unilateral –suspect malignancy Contralateral - benign causes Bells palsy Melkersson’s syndrome-alternating F.N palsy Bilateral concurrent facial nerve palsy : systemic conditions Guillain-Barre syndrome(mc), Leukemia ’ Sarcoidosis , Lyme disease,rabies ,IMN, Moebius syndrome

78. Progressive Facial nerve palsy over a period of more than three weeks or an incomplete facial nerve palsy that does not start to recover after 3-6weeks –suspect underlying neoplasm.

79. BELL’S PALSY Most common cause for facial palsy. Defined as idiopathic LMN facial paralysis or paresis of acute onset. > 60 – 75% 80-90% complete recovery 15-45yrs Both sexes affected equally. Diagnosis of exclusion Positive family history

80. Sudden onset (over 48 hours) Unilateral weakness of all facial muscles Usually following a viral prodrome No evidence of CP angle lesions No evidence of other CNS pathology, No history of ear disease, trauma, facial vesicles

81. the cause of Bell palsy remains unknown, though possible viral, inflammatory, autoimmune, and ischemic etiologies herpes simplex type I as the most likely agent herpes zoster virus, Epstein-Barr virus, Cytomegalovirus, Human immunodeficiency virus [HIV], Lyme disease, Syphilis and Mycoplasma.

82. diabetes have 30% higher risk Pregnant females have 3.3 times higher risk A positive family history-5% Pathophysiology: most accepted theory states that edema and ischemia result in compression of the facial nerve within fallopian canal As the edema within the nerve increases axonal flow and circulation are inhibited labyrinthine segment is the narrowest

83. (the meatal foramen) has a diameter of only about 0.68 mm. most likely site of lesion in Bell's palsy a physiological bottleneck 90% of patients recovering completely within one month.

84. The risk factors thought to be associated with a poor outcome ( 1) Age greater than 60 years (2) Complete paralysis (3) Decreased taste or salivary flow Recurrence rate is about 4- 14%

85. treatment early use of corticosteroids in Bell’s palsy (within 72 hours from the onset of symptoms) Prednisone 1 mg/kg or 60 mg/day for 6 days, followed by a taper, for a total of 10 days Acyclovir at a dosage of 400 mg orally 5 times daily may be used for 10 days. Physiotherapy Eye care: to prevent exposure keratitis, ulceration&blindness

86. T he rationale behind surgical decompression is based on the assumption that the site of maximal facial nerve injury in Bell's palsy is within the meatal foramen. Surgery may be considered in patients with complete Bell palsy that has not responded to medical therapy and with greater than 90% degeneration as shown on electroneuronography within 3 weeks of the onset of paralysis. best surgical results were obtained when the procedure was done within 14 days after onset of paralysis

87. TRAUMATIC FACIAL NERVE PALSY the second most common cause of facial nerve paralysis skull base fractures, gunshot wounds, penetrating injuries of face, blunt trauma, and iatrogenic injuries during surgery

88. TRAUMA Longitudinal(80) Features of temporal bone Transverse(20) Facial nerve palsy common in transverse (50%): perigeniculate region: labrinthine and mastoid segments sensorineural hearing loss, vertigo, hemotympanum Longitudinal fractures:. Facial nerve injury occurs in around 10 % of these fractures : perigeniculate region

89. Due to intraneural haematoma,compression by a bony spicule or transection of nerve. The preferred investigation in such cases of traumatic facial palsy is a high resolution CT scan of the temporal bone Management: complete facial nerve paralysis with an obvious fracture on CT, surgical exploration ; as early as possible Remove fracture fragments, evacuate hematoma, end to end anastomosis in complete transection Severely damaged fragments:interpositional grafts from the greater auricular or sural nerve

90. For incomplete or for delayed onset paralysis facial nerve testing should be obtained on day 4 after onset advanced degeneration has occurred, the nerve should be surgically explored and decompressed.

91. Facial palsy in Tympanomastoid surgery commonest cause of iatrogenic facial palsy If observed during surgery : immediate repair If paralysis is noted immediate postoperatively and the surgeon is confident that the nerve was intact at the conclusion of case, tight ear packing is removed and the patient is observed to allow effect of possible local anaesthetic agent to wear off.

92. HRCT& Facial nerve testing on 4-6 th day degeneration is evident, immediate surgical exploration should be done. Post op delayed onset :steroid therapy

93. INFECTIONS HERPES ZOSTER OTICUS(RAMSAY HUNT SYNDROME ) Facial paralysis with vesicular rash in external auditory canal & pinna . Reactivation of latent VZV in geniculate ganglion May be with giddiness, anaesthesia of face, hearing impairment due to involvement of v & viii nerves.

94. Patient may present with severe pain deep within the ear radiating outwards. characteristic vesicular eruption on the concha, external auditory canal, anterior tongue and palate : 80% of patients. Ramsay Hunt syndrome can also occur in the absence of a skin rash when it is known as zoster sine herpete

95. ipsilateral LMN facial paralysis, varying degrees of sensorineural hearing loss, vertigo, tinnitus, facial numbness and other cranial neuropathies facial palsy is more severe and carries a much poorer prognosis compared to Bell's palsy Mainstay of treatment is corticosteroids, oral acyclovir (800mg 5 times daily) MAY BE GIVEN FOR 2-3 WEEKS and eye care. Vestibular suppressants are used for severe vertigo and Carbamazepine for neuralgic pain.

96. ACUTE OTITIS MEDIA Acute otitis media presenting with facial palsy: congenital dehiscence of the fallopian canal which may serve as portals for direct bacterial invasion and inflammation along the nerve begin within a few days of onset of an acute otitis media and is usually incomplete; this generally resolves with aggressive management of the infection

97. Hence treatment includes myringotomy with drainage of middle ear and culture directed antibiotic therapy .

98. CHRONIC OTITIS MEDIA Chronic Otitis Media may also develop facial paralysis which is usually secondary to cholesteatoma erosion of the fallopian canal or from inflammation leading to osteitis and granulations compressing the facial nerve HRCT temporal bone Tympanomastoid exploration and facial nerve decompression

99. TUBERCULOUS OTITIS MEDIA tuberculous otitis media : with facial nerve palsy other features like multiple perforations, foul smelling otorrhea , pale granulations and disproportionate hearing loss may provide clue to diagnosis.

100. MALIGNANT OTITIS MEDIA Malignant otitis externa severe nocturnal otalgia , ear discharge, canal granulations and facial palsy confirmed by a positive bone scan Treatment of choice is third generation cephalosporins ( ceftazidime ).

101. Melkerson -Rosenthal Syndrome A triad of symptoms: recurrent orofacial edema (lips, tongue, palate and face), recurrent facial palsy, and fissured tongue (lingua plicata/ scrotal tongue ). Recurrent nonpitting orofacial edema that cannot be explained by infection, malignancy, or connective tissue disorder Facial paralysis may be seen only in one third of the patients A history of recurrent alternating paralysis and relapse after initial recovery is common.

102. Etiology of this syndrome is largely unknown, but infection, allergy, autoimmune, genetic and lymphogranulomatosis has been proposed Diagnosis is clinical , but biopsy of the lips may reveal noncaseating granulomas. Facial nerve decompression may be indicated if episodes of paralysis are frequent and progressive

103. Sarcoidosis : multisystem disease of unknown etiology characterized by formation of noncaseating granulomas. ISOLATED FACIAL NERVE PLASY OR AS PART OF HEERDFORT SYNDROME organs affected are lungs but lymph nodes, eyes, nervous system, heart, kidneys, bones, and joints may also be involved; Involvement of the central nervous system ( neurosarcoidosis ) occurs in 5-15% of cases of sarcoidosis . The facial nerve is the most common cranial nerve affected; either unilateral or bilateral involvement may occur

104. Congenital Facial Paralysis commonest cause of facial palsy at birth is birth trauma (80%); from direct pressure during forceps delivery use or from pressure on face by the sacral prominence during delivery.  The chorda tympani often leave the temporal bone through the stylomastoid foramen in neonates and gain its adult position only when the mastoid process develops. Hence in birth trauma to facial nerve there can be associated atrophy of taste papillae on the anterior two thirds of the tongue due to crushing of the nerve at the stylomastoid foramen.

105. should undergo electrical testing of the facial nerve in the first 3 days after birth to ascertain the integrity of the nerve Mobeius Cardio facial Trecher collins Goldenhaurs syndrome

106. Mobius' syndrome is characterized by bilateral absence of facial and abducent nerve function due to congenital hypoplasia of the nucleii Other cranial nerves may also be involved (III, IV, IX, X, XII) and skeletal abnormalities expressionless face, sixth nerve palsy causing abnormal ocular abduction and congenital musculoskeletal abnormalities like brachial deformities, club foot and pectoral muscle hypoplasia.

107. Miehlke syndrome is congenital VIIth and VIth cranial nerve palsy along with atresia of external canal secondary to the teratogenic effect of maternal Thalidomide ingestion Surgical repair in developmental facial paralysis using a peripheral branch may not be very successful majority the nerve is reduced to a few axons and fibrous strands within temporal bone

108. REHABILITATION OF THE PARALYSED FACE GOALS FUNCTIONAL Eye protection Oral competence COSMETIC Symmetry at rest Volational movement Facial expressions

109. MANAGEMNERT OF FACIAL NERVE PARALYSIS SUPPORTIVE MEDICAL SURGICAL EYE CARE COMBINE ALL FOUR TREATMENT DEPEND ON , DURAUION , TYPE , CAUSE AND LOCATION

110. MEDICAL TAB PREDNISOLONE 1 GM/KG/DAY IN DIVIDED DOSE FOR 5 DAYS FOLLOWED BY 10 DAYS TAPERING PREVENT PERMANENT PARALYSIS PREVENT PROGRESSION FASTER RECOVERY ANTIVIRAL 800MG 5 TIMES DAILY FOR 10 DAYS VALCYCLOVIR 1000MG /DAY 7 DAYS

111. Role of surgery in facial palsy : dependent on the aetiology In general the absolute indications for surgical intervention facial nerve are Compression from trauma or fracture Chronic middle ear infection and cholesteatoma causing erosion of facial canal Facial nerve tumors

112. Anastomosis may be end-to-end or translocation anastomosis depending upon the presence of tension at the cut ends Nerve conduits( upto 3 cm ) using laminin , collagen , porcine material . Glue Graft materials used are great auricular nerve, antebrachial cutaneous nerve or sural nerve. In longstanding cases hypoglossal facial nerve anastomosis may be attempted.

113. SURGICAL REANIMATION TECHNIQUE BROADLY CLSSIFIED INTO NEURAL METHODS Facial nerve decompression End to e nd anstom osis Nerve graft Nerve transfer Hypoglossal to facial Spinal accessory to facial Phrenic to facial Masseter to facial nerve

114. 6. Musculo facial transpositions -- move new muscles and nerves into face to take place of the previous

115. OTHER CLASSIFICATION STATIC- SLINGS GOLD WEIGHT TARSSORAPHY / lat canthopexy LOWER LID SHORTENING Wedge resection of lower lip DYNAMIC NERVE GRAFTING MUSCLE TRANSFER 1 .regional 2 .free flap

116. Dynamic Sling surgery LABBE TECHNIQUE / LENGTHENING TEMPORALIS MYOPLASTY

117. Gracilis Microvascular Facial Reanimation

118. include decompression, nerve repair and in late stages plastic surgeries. . Methodologies for surgical intervention are facial nerve decompression, anastomosis, or grafting Decompression may be done via trans canal, trans mastoid, middle fossa or combined approaches

119. ADJUNCTIVE PROCEDURES SODT TISSUE PROCEDURES TO IMPROVE SYMMETRY RHYTIDECTOMY EXCISION OF REDUNTANT INTRAORAL MUCOSA BLEPHAROPLASTY BROWLIFT PROCEDURE FOR DROOLING - WILKIE PROCEDURE

120. THANK YOU