Lindell R. Gentry, M.D.
Facial Paralysis: Objectives: • Discuss the anatomy of the facial nerve
• Look at common patterns of facial nerve palsy
• Discuss imaging appearance of lesions that lead to facial paralysis.
Facial Nerve Anatomy: Facial Nerve Anatomy:
Facial Nerve Anatomy: Facial Nerve Anatomy:
Branchial Motor (Main Facial Nerve) - Muscles of facial expression
Greater Superficial Petrosal Nerve - Autonomic (parasympathetic)
Chorda Tympani Nerve - Taste to anterior 2/3 tongue
Posterior Auricular Nerve - Periauricular region
Facial Nerve Anatomy:
Muscles of Facial Expression
Greater Petrosal Nerve
Motor Root
Facial Nerve
Chorda Tympani
Sensory Root
Nerve to Stapedius
Facial Nerve Anatomy:
• Loss of Function – Central Facial Palsy – Peripheral Facial Palsy
• Hyperactive Function – Hemifacial Spasm
Facial Nerve: Symptoms Facial Nerve: Symptoms • Facial Weakness (Muscles of Facial Expression)
• Loss of Taste – Anterior 2/3 of the tongue
• Hyperacusis
• Loss of Lacrimation
Central Palsy 1. Suprabulbar - Supranuclear
– Sparing of the upper face
2. Brainstem – Other CN Palsies (CN 5-6) – May or may not spare upper face
Peripheral Palsy 1. Intratemporal
– Loss of lacrimation – Hyperacusis – Loss of taste to anterior 2/3 of tongue
2. Intraparotid – Pure motor
Facial Nerve Palsy: Location
Optimal imaging workup: - depends on location of offending lesion - depends on pathology - depends on acuity
Facial Nerve Palsy: Location Central Facial Palsy Peripheral Facial Palsy
Left Facial Palsy with Sparing of the Upper Face
Facial Nerve Palsy: Location Central Palsy
1. Suprabulbar - Supranuclear – Sparing of the upper face
2. Brainstem – Other CN Palsies (CN 5-6) – May or may not spare upper face
Peripheral Palsy 1. Intratemporal
– Loss of lacrimation – Hyperacusis – Loss of taste to anterior 2/3 of tongue
2. Intraparotid – Pure motor
Facial Nerve Palsy: Location Central Palsy
1. Suprabulbar - Supranuclear – Sparing of the upper face
2. Brainstem – Other CN Palsies (CN 5-6) – May or may not spare upper face
Peripheral Palsy 1. Intratemporal
– Loss of lacrimation – Hyperacusis – Loss of taste to anterior 2/3 of tongue
2. Intraparotid – Pure motor
Lymphoma
6th and 7th CN Palsy
Meningoencephalitis
57 Y/O diabetic with HA, hearing loss, facial pain and lower facial palsy
Central Palsy 1. Suprabulbar - Supranuclear
– Sparing of the upper face
2. Brainstem – Other CN Palsies (CN 5-6) – May or may not spare upper face
Peripheral Palsy 1. Intratemporal
– Loss of lacrimation – Hyperacusis – Loss of taste to anterior 2/3 of tongue
2. Intraparotid – Pure motor
Facial Nerve Palsy: Location Central Palsy
1. Suprabulbar - Supranuclear – Sparing of the upper face
2. Brainstem – Other CN Palsies (CN 5-6) – May or may not spare upper face
Peripheral Palsy 1. Intratemporal
– Loss of lacrimation – Hyperacusis – Loss of taste to anterior 2/3 of tongue
2. Intraparotid – Pure motor
Facial Nerve Palsy: Location
Parotid Adeno Ca
CN 7 Schwannoma
Facial Nerve Palsy: Location Central Palsy
1. Suprabulbar - Supranuclear – Sparing of the upper face
2. Brainstem – Other CN Palsies (CN 5-6) – May or may not spare upper face
Peripheral Palsy 1. Intratemporal
– Loss of lacrimation – Hyperacusis – Loss of taste to anterior 2/3 of tongue
2. Intraparotid – Pure motor
• Neoplasm - Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants CN 7 Schwannoma
Peripheral Facial Nerve Palsy:
• Neoplasm - Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants
Peripheral Facial Nerve Palsy:
CN 7 Schwannoma
• Neoplasm - Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants CN 7 Schwannoma
Peripheral Facial Nerve Palsy:
• Neoplasm - Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants CN 7 Schwannoma
Peripheral Facial Nerve Palsy: • Neoplasm
- Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants CN 7 Schwannoma
Peripheral Facial Nerve Palsy:
• Neoplasm - Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants
Peripheral Facial Nerve Palsy:
CN 7 Schwannoma
• Neoplasm - Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants CN 7 Schwannoma
Peripheral Facial Nerve Palsy:
Courtesy of Michelle Michel CN 7 Schwannoma
• Neoplasm - Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants
Peripheral Facial Nerve Palsy:
Plexiform Neurofibroma
• Neoplasm - Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants
Peripheral Facial Nerve Palsy:
V1
V2 V3
V3
V2
V3
CN 7 CN 7
V2
Auriculotemporal Nerve
CPA Meningioma
• Neoplasm - Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants
Peripheral Facial Nerve Palsy:
Nasopharyngeal SCCA
• Neoplasm - Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants
Peripheral Facial Nerve Palsy:
• Neoplasm - Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants
Peripheral Facial Nerve Palsy:
Smoker
• Neoplasm - Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants
Peripheral Facial Nerve Palsy:
Renal Cell Met Smoker
“Dropped” Metastasis
• Neoplasm - Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants
Peripheral Facial Nerve Palsy:
SCCA of Cheek
• Neoplasm - Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants
Peripheral Facial Nerve Palsy:
• Neoplasm - Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants
Peripheral Facial Nerve Palsy:
Adenoid Cystic Ca
• Neoplasm - Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants
Peripheral Facial Nerve Palsy:
• Neoplasm - Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants
Peripheral Facial Nerve Palsy:
Adenoid Cystic Ca
• Neoplasm - Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants
Peripheral Facial Nerve Palsy:
Glomus Jugulare Smoker
Glomus Faciale
• Neoplasm - Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants
Peripheral Facial Nerve Palsy: Progressive facial paralysis secondary to a rare temporal bone tumor: Glomus faciale. Parker, NP & Huang, TC. Archives of Oto- HNS, 137:712-715. DOI: 10.1001/archoto.2011.96-a
• Neoplasm - Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants
Peripheral Facial Nerve Palsy:
Intraosseous Venous Malformation
Idiopathic - Bell’s Palsy - Other Viral
Specific - Bacterial (strep, H Flu, staph, pseudomonas)
- Spirochete (syphilis, Lyme) - Fungal (blastomycosis, mucormycosis, aspergillosis)
- Viral (herpes zoster) - TB
• Neoplasm - Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants
Peripheral Facial Nerve Palsy: Demographics
- Very common cause of facial paralysis - Afflicting 1 in 65 individuals - More common (elderly, DM, pregnancy, immunosuppressed)
Etiology - Viral prodrome (60%) - Unknown, probably viral (HSV 1)
Features - Abrupt, isolated, unilateral, paralysis entire face - Hyperacusis, decreased tearing, dysgeusia - Symptoms peak within days - No imaging required with these typical features
• Neoplasm - Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants
Peripheral Facial Nerve Palsy:
Herpetic (Bell’s) Palsy
• Neoplasm - Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants
Peripheral Facial Nerve Palsy: Imaging
– Herpetic (Bell’s) Palsy is a clinical diagnosis – Imaging only required in atypical presentations – MRI to exclude other causes (CVA, neoplasm, TB infection)
Treatment – Observation – Nerve regenerates at 1-2 millimeters per day – Steroids, antivirals may slightly improve outcome – Surgical decompression controversial
Prognosis – Recovery = 85% Full recovery
= 10% Partial deficit = 5% Complete deficit
– Duration = 50% few months = 35% within a year
– Recurrence = 10 - 20%
• Neoplasm - Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants
Peripheral Facial Nerve Palsy:
Herpetic (Bell’s) Palsy
• Neoplasm - Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants
Peripheral Facial Nerve Palsy: • Neoplasm
- Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants
Peripheral Facial Nerve Palsy:
Herpetic (Bell’s) Palsy
Background – J. Ramsay Hunt (1907)
Clinical Triad – Otalgia (+/- before paralysis) – Facial paralysis – Herpetic eruptions
Etiology – Varicella zoster (HV-3)
Features – CN 8 dysfunction (> Bell’s) – Vertigo, hearing loss, tinnitus – Peri-auricular edema – < 50% complete recovery
• Neoplasm - Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants
Peripheral Facial Nerve Palsy: Role of Imaging
– Limited – Exclude other lesions
CN 7 Enhancement – Geniculate ganglion – Labyrinthine segment facial nerve – IAC meninges – Degree enhancement not prognostic – Peri-auricular soft tissue edema > Bell’s
Treatment – IV acyclovir and steroids – No role for nerve decompression
• Neoplasm - Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants
Peripheral Facial Nerve Palsy:
Acute Pre-eruption Phase
• Neoplasm - Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants
Peripheral Facial Nerve Palsy: • Neoplasm
- Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants
Peripheral Facial Nerve Palsy:
Cholesteatoma
• Neoplasm - Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants
Peripheral Facial Nerve Palsy: • Neoplasm
- Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants
Peripheral Facial Nerve Palsy:
Cholesteatoma
Aggressive Otitis Externa
• Neoplasm - Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants
Peripheral Facial Nerve Palsy: • Neoplasm
- Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants
Peripheral Facial Nerve Palsy:
Blastomycosis
• Neoplasm - Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants
Peripheral Facial Nerve Palsy:
Wegener’s Granulomatosis
• Neoplasm - Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants
Peripheral Facial Nerve Palsy:
Incidence – Intralabyrinthine Fxs 30- 50% – Extralabyrinthine Fxs 10- 20%
Location of Injury – Perigeniculate 80% – Proximal mastoid 12% – Multiple sites 20%
Etiology
– Bony spicules 46% – Contusion / edema 36% – Transection 9% – Intraneural hematoma 9%
• Neoplasm - Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants
Peripheral Facial Nerve Palsy: • Neoplasm
- Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants
Peripheral Facial Nerve Palsy:
• Neoplasm - Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants
Peripheral Facial Nerve Palsy:
Degree 1. Immediate Onset 2. Delayed Onset
Management questions 1. Location Injury 2. Etiology Injury? 3. Surgical Guidance
• Neoplasm - Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants
Peripheral Facial Nerve Palsy:
• Neoplasm - Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants
Peripheral Facial Nerve Palsy: • Neoplasm
- Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants
Peripheral Facial Nerve Palsy:
Facial Nerve Prolapse
• Neoplasm - Primary - Metastasis - Meningeal - Perineural Spread (H&N) - Vascular
• Infection-Inflammatory - Herpetic (Bell’s) Palsy - Herpes Zoster Oticus - Mastoiditis - Cholesteatoma - Other
• Trauma • Other
- Normal Variants
Peripheral Facial Nerve Palsy: Objectives: • Reviewed the anatomy of the facial nerve
• Looked at common patterns of facial nerve palsy
• Discuss imaging appearance of common and uncommon lesions that lead to facial paralysis.
Facial Paralysis:
Lindell R. Gentry, M.D.
Central Facial Palsy Peripheral Facial Palsy
Top Related