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Transcript of Facial nerve - fac.ksu.edu.sa file– Common trunk (nervus intermedius and VII nerve) – Greater...
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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
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Facial Nerve•• EmbryologyEmbryology• Anatomy• Physiology• Pathology
– Pathophysiology– Evaluation – Causes
• Treatment
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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 )
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Facial Nerve• Embryology
•• AnatomyAnatomy• Physiology• Pathology
– Pathophysiology– Evaluation – Causes
• Treatment
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Facial Nerve• 10,000 neurons• 7,000 myelinated facial expression.• Superiorly along the roof of the IAC (7UP)• The course 7segments
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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)
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Pons4 Ss Nuclei1. Solitarius (Taste)2. Superior salivatory nucleus 3. Spinal nucleus of the trigeminal nerve4. Seventh motor
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Solitarius
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Superior salivatory nucleus
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Motor part
• Precentral gyrus (frontal lobe)• Upper face corticobulbar
cross • Contralateral predominance• Motor fiber bend around the
abducens ( CN VIth) nucleus
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TZBMC
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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
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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
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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
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Pes anserinus (goose's foot )
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Facial Nerve• Embryology• Anatomy
•• PhysiologyPhysiology• Pathology
– Pathophysiology– Evaluation – Causes
• Treatment
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Physiology• Lacrimation• Expression• Mastication• Salivation• Speech• Hearing
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Facial Nerveتعرف في وجوه الذين آفروا (•
الحج ).. المنكر بالوجه خمسًا و خمسين عضلة •الوجه مرآة النفس و أن عليه •
تنعكس حاالت اإلنسان السيما العاطفية
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Facial Nerve• Embryology• Anatomy• Physiology• Pathology
––PathophysiologyPathophysiology– Evaluation – Causes
• Treatment
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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
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Facial Nerve PalsyRegeneration• Axonal stumps swell and proliferating neurofilaments• Misdirected regrowth of nerve fibers
• Facial muscle contractures Synkinesia• Salivation crocodile tears
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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
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House-Brackmann• Grade 1
– = Neurapraxia– Spontaneous recovery
• Grade 2-3 – =Axonotmesis– Flow interruption – Wallerian anterograde degeneration. – Incomplete degeneration
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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
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Facial Nerve• Embryology• Anatomy• Physiology• Pathology
– Pathophysiology
––EvaluationEvaluation– Causes
• Treatment
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Evaluation• Careful history • Physical exam• Audiometry• CT/MRI/other• Topographic• Electrophysiology
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History• Timing• Associated symptoms • SNHL• Vesicles• Severe pain• Trauma• OM acute or chronic• Past medical history
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Physical exam• Complete head and neck exam
• Wide smile • Whistling • Blowing
• LMNL– Forehead wrinkling– Eye closure– Bell’s phenomenon
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Topognostic Tests• Schirmer’s Test• Stapedial reflex• Taste• Salivary Flow• Imaging
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Evaluation Facial Nerve PalsyElectro-Physiology• Electroneurography (ENoG)
• Electromyography (EMG)
• Nerve excitability test (NET)
• Maximum stimulation test (MST)
ACUTE=Acute+Complete+Unilateral+Threedays Evaluate
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Facial Nerve• Embryology• Anatomy• Physiology• Pathology
– Pathophysiology– Evaluation
––CausesCauses• Treatment
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Facial Nerve Palsy
Causes:• Congenital
• Trauma
• Iatrogenic
• Idiopathic
• Infection
• Toxic
• Neurologic
• Neoplastic
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Facial Nerve PalsyTrauma• Forceps delivery
• Basal skull/temporal bone fractures
• Facial injury
• Penetrating to middle ear
• Barotrauma
• Lightning
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Racoon eyes sign
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Battle’s sign
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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
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Fractures• Longitudinal
– 80% of Temporal Bone Fractures– 15-20% Facial Nerve involvement
• Transverse– 20% of Temporal Bone Fractures– 50% Facial Nerve Involvement
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R
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Facial Nerve Palsy
Iatrogenic• Parotid surgery
• Mastoid surgery
• local anesthesia
• Acoustic neuroma
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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
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Iatrogenic Facial Nerve Palsy
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Iatrogenic Facial Nerve Palsy
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Facial Nerve PalsyIdiopathic• Bell’s
• Melkersson-Rosenthal
• Guillian-Barre
• MS
• Myasthenia gravis
• Sarcoidosis (Heerfordt’s)
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Bell's Palsy• Commonest cause of acute VII paralysis• Diagnosis of exclusion• Unilateral facial paralysis • Sudden onset • Unknown cause• LMNL
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Bell's Palsy• Limited duration• Minimal symptoms• Spontaneous recovery• No sensory loss
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Bell's Palsy? Immune or viral Swelling of the nerve
Compression and ischemiaComplete paralysis
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Diagnosis• Weakness of the entire half of the face • In doubt CT and MRI scans • MRI may show contrast enhancement
of the facial nerve
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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
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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
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Melkersson-Rosenthal
4 Fs• Facial nerve palsy
(Recurrent )
• Furrowed tongue
• Faciolabial edema
• FHx + ve
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Melkersson-Rosenthal
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Sarcoidosis (Heerfordt’s)
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Facial Nerve PalsyInfection• Malignant otitis externa
• Otitis media
• Mastoiditis
• Ramsey Hunt (Herpes zoster)
• Encephalitis
• Polio
• Syphilis
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Malignant Otitis Externa
4 Ds• Diabetes mellitus • Discharge (Purulent )• Discomfort• Dysfunction Cranial nerve
• Granulation obscured TM
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Otitis media
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Ventilating Tubes
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Mastoiditis
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Ramsay Hunt• Herpetiform vesicular
eruptions (VZV)• Painful• vestibulocochlear
dysfunction• Treatment is equivalent to
Bell palsy• Poor outcome
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Facial Nerve PalsyNeoplastic• Malignant parotid lesion
• Cholesteatoma
• Acoustic neuroma
• CN VII tumor
• Meningioma
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NeoplasticSPORT Neoplasm• Slowly progressive• Persistent >4 months• Other C.N. Ex SNHL • Recurrent• Tumor History
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Cholesteatoma
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Neoplastic Facial Nerve Palsy
Acoustic neuroma
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Facial Nerve• Embryology• Anatomy• Physiology• Pathology
– Pathophysiology– Evaluation – Causes
•• TreatmentTreatment
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Facial Nerve PalsyFunctional deficits• Lagopthalmos and ectropion
• Oral incompetence
• Nasal obstruction
• Mastication difficulties
• Articulation difficulties
Often severe psychological distress
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Goals of restoration• Corneal protection
• Facial symmetry at rest
• Symmetric smile
• Oral competence
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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
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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
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Restore Neural inputPrimary nerve repair
- Preformed immediately- Small gap (<17mm)- Epineural or perineural- Magnification- No tension- Best outcome- Expect HB III
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Restore Neural input
Interposition graft
- HB III
- Variable synkinesis
- Improvement over 6 to 18 months
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Hypoglossal-facial crossover
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Muscle transposition
Masseter transfer
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Muscle transposition
Temporalis transfer
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Temporalis Muscle transposition
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Non-functional facial musclesFree gracilis
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Non-functional facial muscles
Free gracilis trigeminal innervation
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Static reanimation
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Botulinum Toxin• Synkinesis and hypertonia• Advantages
• Ease of use• Selective
•Disadvantages• Temporary• Repeated every 3 months
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Conclusions• Facial paralysis sequlae (significant)
• Functional• Cosmetic • Psychological
• The primary goals of facial reanimation• Corneal protection• Symmetry at rest • Smile restoration
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ConclusionsPrimary repair
Cable rafting
CN XII-CN VII anastamosis
Static Reanimation
Microneurovascular
Hyperkinetic Botulinum toxin
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Facial Nerve• Embryology• Anatomy• Physiology• Pathology
– Pathophysiology– Evaluation – Causes
• Treatment
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