FACIAL NERVE PLASY Dr.Satguru Saran Singh
Description: FACIAL NERVE PLASY Dr.Satguru Saran Singh Assistant Professor Department of ENT Pons to parotid Mixed nerve sensory root (nerve of wrisberg) Special visceral efferents-motor root General visceral efferent secretomotor fibres to lacrimal
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slide1. FACIAL NERVE PLASY Dr.Satguru Saran Singh
Assistant Professor
Department of ENT<br>
slide2. Pons to parotid
Mixed nerve – sensory root (nerve of wrisberg)<br>
slide3. Special visceral efferents-motor root
General visceral efferent – secretomotor fibres to lacrimal ,submandiblar ,sublingual glands & small secretory glands in nasal mucosa & palate
Special visceral afferent – taste from ant 2/3 rd tongue via chorda tympani ,soft & hard palate via greater superficial petrosal nerve
General somatic afferents –general sensation from concha,postero-sup part of external canal & tympanic memb<br>
slide4. Motor ncleus – pons<br>
slide10. Intracranial
Intratemporal
Extracranial<br>
slide11. INTRACRANIAL Intracranial part –From pons to Internal Acostic meatus
15-17 mm<br>
slide12. Intratemporal Frm IAM to stylomastoid foramen Meatal segment – 8-10 mm ,within IAM
Labyrinthine segment 4 mm – fundus of meatus to geniclate ganglion
shortest segment
Narrowest – 0.61- 0.68 mm
Tympanic segment 11mm –frm GG to just above pyramidal eminence
Mastoid / vertical segment – 13 mm
Frm pyramid to Stylomastoid foramen<br>
slide15. Extracranial Frm stylomastoid foramen to peripheral branches<br>
slide19. BRANCHES Greater superficial petrosal nerve –frm GG & carries secretomotor fibres to lacrimal gland & glands of nasal mucosa and palate
Nerve to stapedius – Arises at level of 2nd genu & supplies stapedius muscle
Chorda tympani – middle of vertical segment , passes btw incus & neck of malleus & leaves thru petrotympanic fissure.
it carries secretomotor fibres to submandibular ,sublingual glands ,brings taste from ant 2/3rds of tonge<br>
slide20. Muscular branches – stylohyoid & post belly of digastric
Peripheral branches
Upper- temperofacial
Lower-cervicofacial
Temporal
Zygomatic
Buccal
Marginal mandiblar
cervical<br>
slide21. BLOOD SUPPLY Anteroinf cerebellar artery - CP angle
Labyrinthine artery –IAC
Superficial petrosal artery –GG
Stylomastoid artery – mastoid & tympanic segment<br>
slide24. Cartilaginous pointer – nerve lies 1 cm deep & slightly anterior & inf to pointer.
Tympanomastoid suture – Nerve lies 6-8 mm deep to suture.
Styloid process – nerve crosses lateral to styloid process.
Posterior belly of digastric – nerve lies between it & styloid process.<br>
slide29. Electrodiagnostic tests Minimal nerve excitabilty tests – diff btw 2 sides exceeds 3.5 amp ,test + for degeneration
48- 72 hr .
Maximal stimulation test – equal , decreased ,absent
Decreased /absent – degeneration
Electroneuronography –degeneration of 90% occuring in 1st 14 days –poorer prognosis
Electromyography –motor activity of facial muscles.
Fibrillation potentials –spont invol action potentials in a denervated muscle.(14-21 after denervation )
Polyphasic reinnervation -6-12 wks prior to clinical evidence<br>
slide30. Central
brain abscess
pontine gliomas
polio
multiple sclerosis
Intracranial part (CP angle)
Acoustic neuroma
meningioma
cong cholesteastoma
metastatic carcinoma
meningitis<br>
slide31. Intratemporal part
idiopathic-bells palsy
- melkersson syndrome
Infectious-asom,csom,herpes zoster otics,MOE
Trauma – surgical :mastoidectomy & stapedectomy
Accidental: fractures of temporal bone
Neoplasms- malignancies of ext & middle ear,glomus tmr,facial nerve neuroma,mets to temporal bone<br>
slide32. Extracranial –malignancy of parotid,surgery of parotid ,accidental injury in parotid,neonatal facial injury (obstetrical forceps )
Systemic diseases –DM , hypothyroidis,uraemia,polyarteritis nodosa,wegeners granulomatosis ,sarcoidosis,leprosy,lekemia,demyelinating disease<br>
slide33. BELLS PALSY 60-75% of facial paralysis
Idiopathic , peripheral facial paralysis or paresis of acute onset.
Equal sexes affected
Any age grp maybe affected
Postive family history -6-8 %
Risk is more in DM ,pregnant women<br>
slide34. AETIOLOGY Viral infections – HSV ,HZ,EBV
Vascular ischemia –pri –cold,emotional stress
sec – result of pri ischaemia
Hereditary
Autoimmune disorder<br>
slide37. Diagnosis By exclusion
History
Ent examination
X ray studies
Blood sugar
Serology
Nerve excitabilty tests
Topodiagnostic tests<br>
slide38. general Reassurance
Analgesics
Eye care
physiotherapy<br>
slide39. medical Steroids – prednisolone 1mg/kg
Surgical - nerve decompression – vertical & tympanic segmnent
Prognosis – 85-90% recover fully<br>
slide40. Melkersson syndrome Idiopathic
Triad - facial paralysis, lip swelling ,fissured tonge
recurrent<br>
slide41. Recurrent facial palsy Bilateral facial palsy Bells palsy
Melkersson syndrome
Diabetes
Sarcoidosis
Tumours
Recurrent palsy on same side – tmrs in 30 % Gillain barre syndrome
Sarcoidosis
Sickle cell disease
Acute leukemia
Bulbar palsy
Leprosy
Systemic diseases<br>
slide42. Ramsay hunt syndrome/Herpes zoster oticus Facial palsy
Vesicular rash eac & pinna
Anaesthesia of face , giddiness<br>
slide43. Temporal lobe fractures<br>
slide45. UMN- opp side lower half,wrinkling +,invol emotional movements,tone of facial muscles +
Nucleus – 6th cn palsy
CP angle –vestibular+ auditory defects,V,IX,X,XI CN
Bony canal – frm IAM to SMF –topodiagnostic tests<br>
slide46. SCHIRMER TEST Lesion – proximal to GG - secretomotor fibres to lacrimal gland at the GG via GSPN
Filter paper – no.41 whatman – 5mm wide 35 mm length
< 10 mm after 5 mins - abnl<br>
slide47. Stapedial reflex Lost in lesions above n. to stapedius<br>
slide48. Taste test Lesion above chorda tympani<br>
slide49. Submandibular salivary flow test decreased saivation – Lesion above chorda tymapani<br>
slide50. complications Incomplete recovery
Exposure keratitis
Synkinesis ( mass movements ) –cross innervation
Contractures
Psychological & social problems<br>
slide52. Freys syndrome /gustatory sweating Sweating & flushing of skin over parotid area during mastication
Parotid surgery<br>
slide53. Facial nerve surgery Decompression
End to end anastomosis
Nerve /graft cable- greater auricular ,sural nerve,lateral cutaneous nerve of thigh
Hypoglossal –facial anastomsis
Plastic procedures – facial slings , face lift operation,slings of masseter & temporalis muscle<br>
Assistant Professor
Department of ENT<br>
slide2. Pons to parotid
Mixed nerve – sensory root (nerve of wrisberg)<br>
slide3. Special visceral efferents-motor root
General visceral efferent – secretomotor fibres to lacrimal ,submandiblar ,sublingual glands & small secretory glands in nasal mucosa & palate
Special visceral afferent – taste from ant 2/3 rd tongue via chorda tympani ,soft & hard palate via greater superficial petrosal nerve
General somatic afferents –general sensation from concha,postero-sup part of external canal & tympanic memb<br>
slide4. Motor ncleus – pons<br>
slide10. Intracranial
Intratemporal
Extracranial<br>
slide11. INTRACRANIAL Intracranial part –From pons to Internal Acostic meatus
15-17 mm<br>
slide12. Intratemporal Frm IAM to stylomastoid foramen Meatal segment – 8-10 mm ,within IAM
Labyrinthine segment 4 mm – fundus of meatus to geniclate ganglion
shortest segment
Narrowest – 0.61- 0.68 mm
Tympanic segment 11mm –frm GG to just above pyramidal eminence
Mastoid / vertical segment – 13 mm
Frm pyramid to Stylomastoid foramen<br>
slide15. Extracranial Frm stylomastoid foramen to peripheral branches<br>
slide19. BRANCHES Greater superficial petrosal nerve –frm GG & carries secretomotor fibres to lacrimal gland & glands of nasal mucosa and palate
Nerve to stapedius – Arises at level of 2nd genu & supplies stapedius muscle
Chorda tympani – middle of vertical segment , passes btw incus & neck of malleus & leaves thru petrotympanic fissure.
it carries secretomotor fibres to submandibular ,sublingual glands ,brings taste from ant 2/3rds of tonge<br>
slide20. Muscular branches – stylohyoid & post belly of digastric
Peripheral branches
Upper- temperofacial
Lower-cervicofacial
Temporal
Zygomatic
Buccal
Marginal mandiblar
cervical<br>
slide21. BLOOD SUPPLY Anteroinf cerebellar artery - CP angle
Labyrinthine artery –IAC
Superficial petrosal artery –GG
Stylomastoid artery – mastoid & tympanic segment<br>
slide24. Cartilaginous pointer – nerve lies 1 cm deep & slightly anterior & inf to pointer.
Tympanomastoid suture – Nerve lies 6-8 mm deep to suture.
Styloid process – nerve crosses lateral to styloid process.
Posterior belly of digastric – nerve lies between it & styloid process.<br>
slide29. Electrodiagnostic tests Minimal nerve excitabilty tests – diff btw 2 sides exceeds 3.5 amp ,test + for degeneration
48- 72 hr .
Maximal stimulation test – equal , decreased ,absent
Decreased /absent – degeneration
Electroneuronography –degeneration of 90% occuring in 1st 14 days –poorer prognosis
Electromyography –motor activity of facial muscles.
Fibrillation potentials –spont invol action potentials in a denervated muscle.(14-21 after denervation )
Polyphasic reinnervation -6-12 wks prior to clinical evidence<br>
slide30. Central
brain abscess
pontine gliomas
polio
multiple sclerosis
Intracranial part (CP angle)
Acoustic neuroma
meningioma
cong cholesteastoma
metastatic carcinoma
meningitis<br>
slide31. Intratemporal part
idiopathic-bells palsy
- melkersson syndrome
Infectious-asom,csom,herpes zoster otics,MOE
Trauma – surgical :mastoidectomy & stapedectomy
Accidental: fractures of temporal bone
Neoplasms- malignancies of ext & middle ear,glomus tmr,facial nerve neuroma,mets to temporal bone<br>
slide32. Extracranial –malignancy of parotid,surgery of parotid ,accidental injury in parotid,neonatal facial injury (obstetrical forceps )
Systemic diseases –DM , hypothyroidis,uraemia,polyarteritis nodosa,wegeners granulomatosis ,sarcoidosis,leprosy,lekemia,demyelinating disease<br>
slide33. BELLS PALSY 60-75% of facial paralysis
Idiopathic , peripheral facial paralysis or paresis of acute onset.
Equal sexes affected
Any age grp maybe affected
Postive family history -6-8 %
Risk is more in DM ,pregnant women<br>
slide34. AETIOLOGY Viral infections – HSV ,HZ,EBV
Vascular ischemia –pri –cold,emotional stress
sec – result of pri ischaemia
Hereditary
Autoimmune disorder<br>
slide37. Diagnosis By exclusion
History
Ent examination
X ray studies
Blood sugar
Serology
Nerve excitabilty tests
Topodiagnostic tests<br>
slide38. general Reassurance
Analgesics
Eye care
physiotherapy<br>
slide39. medical Steroids – prednisolone 1mg/kg
Surgical - nerve decompression – vertical & tympanic segmnent
Prognosis – 85-90% recover fully<br>
slide40. Melkersson syndrome Idiopathic
Triad - facial paralysis, lip swelling ,fissured tonge
recurrent<br>
slide41. Recurrent facial palsy Bilateral facial palsy Bells palsy
Melkersson syndrome
Diabetes
Sarcoidosis
Tumours
Recurrent palsy on same side – tmrs in 30 % Gillain barre syndrome
Sarcoidosis
Sickle cell disease
Acute leukemia
Bulbar palsy
Leprosy
Systemic diseases<br>
slide42. Ramsay hunt syndrome/Herpes zoster oticus Facial palsy
Vesicular rash eac & pinna
Anaesthesia of face , giddiness<br>
slide43. Temporal lobe fractures<br>
slide45. UMN- opp side lower half,wrinkling +,invol emotional movements,tone of facial muscles +
Nucleus – 6th cn palsy
CP angle –vestibular+ auditory defects,V,IX,X,XI CN
Bony canal – frm IAM to SMF –topodiagnostic tests<br>
slide46. SCHIRMER TEST Lesion – proximal to GG - secretomotor fibres to lacrimal gland at the GG via GSPN
Filter paper – no.41 whatman – 5mm wide 35 mm length
< 10 mm after 5 mins - abnl<br>
slide47. Stapedial reflex Lost in lesions above n. to stapedius<br>
slide48. Taste test Lesion above chorda tympani<br>
slide49. Submandibular salivary flow test decreased saivation – Lesion above chorda tymapani<br>
slide50. complications Incomplete recovery
Exposure keratitis
Synkinesis ( mass movements ) –cross innervation
Contractures
Psychological & social problems<br>
slide52. Freys syndrome /gustatory sweating Sweating & flushing of skin over parotid area during mastication
Parotid surgery<br>
slide53. Facial nerve surgery Decompression
End to end anastomosis
Nerve /graft cable- greater auricular ,sural nerve,lateral cutaneous nerve of thigh
Hypoglossal –facial anastomsis
Plastic procedures – facial slings , face lift operation,slings of masseter & temporalis muscle<br>