FACIAL PALSY

INTRODUCTION

Facial nerve is the VII CN.Facial muscles develop from the

mesoderm of second branchial arch.

Facial muscles are remnants of panniculus carnosus ,the subcutaneous muscle of animals.

Motor nucleus of VII CN is antero lateral to VI CN nucleus

Parasympathetic fibres

Red line motor fibers

Visceral afferent fibres

Muscle actionFrontalis –wrinklingCorrugator supercili —

frowning,vertical wrinkles of foreheadOrbicularis oculi—closure of eyesOrbicularis oris—whistlingBuccinator –puffing the mouthDilator of the mouth –showing the

teethPlatysma-forcibly pulling the angle of

mouth downwards and backwards.

Examination of facial nerveShow the teethOpen his mouth—compare nasolabial

foldsClose his eyesFrownWrinkle foreheadRaise eyebrowsBare his teeth and open his mouthBlowing out cheeksPursuing the lips –strength and weakness

U M N FACIAL PALSY

L M N FACIAL PALSY

CASE A 28 yr old female had fever for 12 days followed

by weakness of left half of the face 2 days after subsidence of fever.patient had numbness over the left half of face..mouth was noticed to be deviated to the right side.patient had difficulty in chewing food.dribbling of saliva and running of tears from eyes. h/o pain in the ear and tinnitus prior to onset.patient has no ear disharge.not a diabetic.

On examination patient was having no wrinkles on forehead..unable to close her eyes,whistle,blow out,motuh deviated to right side,could not put out platysma on left side.

A diagnosis of ACUTE COMPLETE LMN FACIAL PALSY was made.

Bell’s palsy

DEFINITIONAcute onset of non suppurative

inflammation of the facial nerve above the stylomastoid foramen,producing a unilateral LMN FACIAL PALSY.

BELL’S PALSY IDIOPATHIC L. M.N FACIAL PALSYHERPES SIMPLEX FACIAL PARALYSIS(ADAM

AND VICTOR’S)HERPETIC FACIAL PARALYSIS—(ADAM AND

VICTOR’S)

Most common form of lower motor neuron facial palsy.

Sudden onset of LMN facial palsy.No other neurologic abnormalities.

BELL’S PALSYcont…Incidence is 23/1,00,000Affects men and women equally , all ages ,all

times of the year.Increased occurrence in the elderly diabetics,

hypertensives than in the common people.Increased incidence in women during the

third trimester of pregnancy 2 weeks preceding delivery ,first two weeks postpartum.

1 in 6o life time occurrence of single episodeFacial palsy reccurs with each pregnancy .

Etiology:Idiopathic Reactivation of the herpes

simplex virus in the geniculate ganglion.

Viral agent has long been suspected –(BARINGER)

Patho physiologyHSV I DNA in the endoneural fluid

.,post auricular muscle---due to reactivation of the virus in the geniuclate ganglion.

Inactivated intra nasal influenza vaccine can cause bells palsy.

No adequate data to support the above relation.

Onset of bell’s palsy is acute.½ of the cases attain maximum

paralysis in 48 hours.All cases are clinically prominent

by 5 days.

Pain behind the ear may precede the paralysis by a day or two .

Impairement of taste is present to some degree in all cases –rarely beyond second week of paralysis.

Hyperacusis or distortion of sound in ipsilateral ear ---paralysis of stapedius muscle.

Patient feels stiffness of face pulled to one side.

Ipsilateral restriction of eye closure, difficulty with eating ,fine facial movements.

Disturbance of taste –chorda tympani fibres

Hyperacusis—fibers to stapedius

Paralysis is partial in 30%,complete in 70%cases.

Emotional fibres are affectedJaw jerk is normalCorneal reflex is absentThese differentiate it from UMN

palsy

BELL’S PHENOMENONNormally on closing the eye ,the

eyeball moves upwards and inwards.

This is obvious on the affected side due to ineffective closure of the eyelids.

ClinicallyCorner of mouth droopsCrease and skin folds effacesForehead is unfurrowedEyelids will not closeEye on the paralysed side rolls upward –BELL’S

PHENOMENONLower lid sags and falls away from conjunctivaTears spill over cheekFood collects between the teeth and lipsSaliva may dribble from the corner of the

mouthHeaviness or numbeness of the faceSensory loss rarely demonstratble

Enhancement of the facial nerve on gadolinium enhanced MRI

Increased lymphocytes ,mononuclear cells in CSF.

Other testsTensilon testShirmer testESRBlood glucose levels

Prognosis80% patients recover within a

few weeks.2-12 weeks.10%--permanent

disfigurement.long term sequelae.

8%--recurrenceBest clinical guide to progress is

the severity of the palsy during the first few days after presentation.

Recovery of taste precedes motor function.

Clinically complete palsy when first seen are less likely to make a full recovery—than incomplete one

Advanced ageHyperacusis—persistentSevere initial pain.

If recovery of taste occurs in first week –good prognostic sign.

Early recovery of motor function in the first 5-7 days— most favourable prognosis.

Recurrence is due to reactivation of virus,pregnancy.

Interval between periods is not predictable.

Treatment

ControversialSymptomatic

◦Protection of eye during the sleep patch◦Massage of the weakened muscles ◦Lubricating eye drops

Prednisolone 60-80 mg/day in divided doses intial 4-5 days,then taper over next 7-10 days.◦Decreases the possibility of permanent

paralysis◦From swelling of facial nerve in facial canal.◦Decreases the severe pain.

Acyclovir alone is not useful.No evidence that surgical

decompression of facial nerve is effective ---may be harmful

Acyclovir 400mg 5 times a day –10 days is not recommended

Valacyclovir 1000mg /day 5-7 days-not recommended.

ComplicationsContracture develops in the

paralysed muscles—normal appearance---evident when patient smiles.

Denervation after ten days---axonal degeneration.

Electromyography Nerve excitability Nerve conduction studies are

useful for prognosis.

Long delay in the onset of recovery—3months

Regeneration of nerve –2 yearsIncomplete

◦Crocodile tears◦Jaw winking◦Synkinesis◦Facial spasms

Sequelae

Hemifacial spasmsPainless Irreuglar contractions on one side of the face.As a sequelae to bell’s palsy. Irritative lesion of facial nerve.---acoustic

neuroma,aberrant artery.,basilar aneurysmTreatment – carbamazepine,gabapentin,Resistant cases – baclofenLocal injection of botulinum toxin Surgical decompression

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SEQUELAE

Facial diplegiab/l LMN facial palsySeen in

◦Guillain barre syndrome◦Miller fischer variant◦Sarcoidosis◦Lyme disease◦Mobius syndrome◦Melkerson rosenthal syndrome

L M N FACIAL PALSY

L M N FACIAL PALSY B/L

MELKERSSEN ROSENTHAL SYNDROMERECURRENT FACIAL PARLAYSISLABIAL EDEMAPLICATION OF TONGUE

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D.DIAGNOSIS Lyme disease Ramsay hunt syndrome Sarcoidosis Guillain barre syndrome Leprosy Diabetes Sjogrens Amyloidosis Melkerson rosenthal syndrome Acoustic neuroma Mutiple sclerosis Middle ear infections Carotid body tumors Cholesteatoma

summary Idiopathic LMN FACIAL palsy is bells’; palsyRecovery is the rulePrednisolone 60- 80 mg for five days .

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