Facial palsy

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1. FACIAL PALSY Dr. Vibhash Kumar Vaidya

2. Contents Introduction Anatomy Epidemiology Cause Clinical Features Differential Diagnosis Ramse Hunt syndrome Evaluation & Diagnosis

3. Treatment Prognosis Complications Physiotherapy management

4. Introduction Facial palsy accounts for 75% of cases of acute facial nerve (7 th cranial nerve) paralysis Imaging is not needed in majority of patients unless they have atypical features W/atypical features, MR & CT may demonstrate potentially treatable lesions affecting facial nerves Facial nerves can be affected anywhere along their course

5. Sir Charles Bell, Scottish Surgeon First described in early 1800s based on trauma to facial nerves Definition of Bell’s Palsy: Acute peripheral CN VII (facial nerve) palsy of unknown cause

6. Anatomy of Facial nerve The facial nerve contains approximately 10,000 fibers 7000 myelinated fibers innervate the muscles of facial expression, stapedius muscle, postauricular muscles, posterior belly of digastric muscle, and platysma 3000 fibers form the nervus intermedius ( Nerve of Wrisberg ) sensory fibers ( taste ) from the anterior 2/3 of the tongue taste fibers from soft palate via palatine and greater petrosal nerve parasympathetic secretomotor fibers to the parotid, submandibular, sublingual, and lacrimal gland

7. Anatomy of Facial nerve 1) Intracranial part Supranuclear segment Nuclear segment Infranuclear segment Cerebellopontine angle Internal acoustic canal Labyrinthine segment Tympanic segment Mastoid segment 2) Extracranial part

8. Supranuclear segment Cerebral cortex  Corticobulbar tract  Facial nucleus (pons) Upper face  crossed & uncrossed Lower face  crossed only

9. Nuclear segment Facial motor nucleus lower 1/3 of Pons abducent nucleus Out from brain stem at pons recess between olive and inferior cerebellar peduncle

10. Infranuclear segment Cerebellopontine angle Internal acoustic canal Labyrinthine segment Tympanic segment Mastoid segment

11. Cerebellopontine angle The facial nerve and nervus intermedius exit the brain stem at the pontomedullary junction and travel with CN VIII to enter the internal acoustic meatus

12. Internal acoustic canal Motor facial nerve (medial) N ervus intermedius (between) Acoustic nerve (lateral)

13. Labyrinthine segment Fallopian canal Shortest & Narrowest part Temporal bone Facial nerve enter fallopian canal until middle ear First genu Geniculate ganglion Branches Greater superficial petrosal nerve  lacrimal gland Lessor superficial petrosal nerve  parotid gland

14. Tympanic segment First genu  above oval window  stapes Second genu beyond middle ear Out of cranium through stylomastoid foramen

15. Mastoid segment Stylomastoid foramen Branches Motor nerve to stapedius muscle Chorda tympani nerve between malleus and incus secretomotor : Submandibular & Sublingual gland taste fiber : anterior 2/3 of tongue

16. Extracranial segment Posterior auricular nerve : auricularis , occipitalis and sensation at auricular, post auricular area Branch to posterior belly of digastric muscle and stylohyoid muscle T emporal branch : muscle above zygoma Z ygomatic branch : orbicularis occli B uccal branch : buccinator and upper lip M arginal mandibular branch : orbicularis oris and lower lip C ervical branch : platysma

17. Epidemiology ½ of all facial palsy’s qualify as “Bell’s Palsy” Annual Incidence 10-40/100,000 Lifetime incidence 1:60 Risk is 3xs greater in pregnancy, especially 3 rd trimester Increased risk with diabetes

18. Cause Widely accepted cause is HSV-1, however not proven HSV mediates inflammatory/immune response which leads to myelin sheath degeneration, & edema which causes compression and further damage of CN VII

19. Clinical Features Sudden onset symptoms, usually hours w/ maximal weakness w/in 48 hrs Unilateral Eyebrow sagging Inability to close eye Loss of nasolabial fold Decreased tearing Hyperacusis Loss of taste to anterior 2/3 tongue Mouth droop

20. Differential Diagnosis Infection External otitis Otitis media Mastoiditis Chickenpox Herpes zoster (Ramsey Hunt syndrome) Encephalitis Poliomyelitis (type I) Mumps Mononucleosis Leprosy Influenza Coxsackievirus Malaria Syphilis Tuberculosis Botulism Lyme disease Tumor, central or local Metabolic DM Hyperthyroidism Vitamin A deficiency Toxic Iatrogenic Idiopathic Bell's Melkersson -Rosenthal syndrome (recurrent alternating facial palsy, furrowed tongue) Amyloidosis Landry- Guillain - Barre syndrome Multiple sclerosis Myasthenia gravis Sarcoidosis Birth Trauma

21. Herpes Zoster Oticus ( Ramsay Hunt Syndrome ) 3 rd most common of peripheral facial paralysis (10%) Aged > 60 yrs. or low immune (low CMIR) Virus travels to the dorsal root extramedullary cranial nerve ganglion Infected of HZV at auricular, external canal or face Prodromal symptoms very similar to those seen in Bell's palsy but usually more severe

22. Herpes Zoster Oticus ( Ramsay Hunt Syndrome ) Symptoms include severe otalgia, facial paralysis, facial numbness, and a vesicular eruption on the concha, external auditory canal, and palate Facial paralysis + hearing loss + vertigo  “ canal paralysis ” Pathophysiology & treatment liked in Bell ’s palsy

23. Evaluation & Diagnosis Bell’s Palsy is a clinical diagnosis based on typical presentation absence of other explanation or other underlying disease absence of cutaneous lesions otherwise normal neuro exam Possible Labs to check: ESR, RPR, Lyme titer, glucose, PCR if vesicular lesions Proceed with imaging (MRI) if Atypical Presentation Slowly progressive over 2-3 weeks If no improvement in symptoms in 6 wks Electrophysiology (CMAP) performed if complete facial paralysis remains after 1 week of treatment

24. Treatment Manual closing of eye such as with tape while sleeping, lubricating eye drops Steroids 60-80 mg daily x 5 days then tapered over next 5 days or 1 mg/kg daily x 7 days +/-Acyclovir 400 mg 5xs daily x 10 days vs Valacyclovir 1 g BID x 7 days Surgical Decompression – no good evidence to support

25. Prognosis 80% recover within weeks to months If motor nerve conduction studies show evidence of denervation after 10 days indicates prolonged recovery of ~ 3 months & possible incomplete recovery

26. Complications Complications of facial nerve decompression dural tears conductive or sensorineural hearing loss vestibular function loss persistent CSF leaks meningitis injury to the anterior inferior cerebellar artery (AICA) or its branches

27. PHYSIOTHERAPY MANAGEMENT GOALS 1- to educate patient about the condition. 2- to relief pain. 3- to establish the bases for re-education of muscle and nerve conduction. 4- to re-educate the sensation if involved. 5- to improve muscle contraction. 6- to improve facial symmetry. 7- to prevent complications.