Facial Nerve

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Facial Nerve

• Bastaninejad Shahin, MD, Otolaryngologist

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VIIth nerve Anatomy
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4mm
11mm
8-10 IAC
15-17 CPA
13mm
Porus Fundus
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G.G.
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Selected Clinical Scenarios
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Bells Palsy

• Spontaneous idiopathic facial paralysis
• paralysis or paresis of all muscle groups of one
  side of the face
• sudden onset
• absence of signs of CNS disease
• absence of signs of ear or cerebellopontine angle
  disease

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• Incidence 20-30/100000, its greater in more than
  65yrs
• M/F ratio is equal, but in less than 20yrs its
  more common in F but in more than 40yrs, its
  more common in M.
• 30 have incomplete paralysis
• 70 have complete paralysis

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Bells Etiology

• Microcirculatory failure of vasa nervorum
• Viral infection ? most accepted concept
• Ischemic neuropathy
• A.I. reaction

HSV Reactivation
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• Other caranial nerve involvment in Bells palsy
  (in more than 50 of the pts)

5,7,9,10 C2
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• Site of involvement proximal Labyrinthine and
  meatal portion
• Prognosis is excellent 80-90 complete recovery
  (95-100 in partial paralysis)
• Poor outcome measures
• Hyperacusis (brain stem reactivation)
• Decreased tearing
• Age more than 60
• DM and HTN
• Severe aural and facial radicular pain

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Bells Palsy (cont)

• Bells in Children
• Female preponderance
• 97 full recovery
• Impact of corticosteroid is uncertain!
• Familial Bells?8
• Recurrent?9.3
• More common in females, and DM sufferers
• No prognostic difference with primary Bells

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Bells in pregnancy

• More frequent in pregnant women (3.3)
• Most common in third trimester or immediate
  postpartum
• Pre-eclampsia is a RF
• Treatment is with prednisolone

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• Management
• Corticosteroids (mainstay) 1mg/kg/day in seven
  days, then taper it down
• Antiviral agents
• Surgery within 2wks if ENOG showed more than 90
  axonal degeneration (Gantz et al.)

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Ramsay Hunt Syndrome (RHS)

• Skin vesicles (aural, facial ,...) faicial
  nerve paralysis
• Relates to VZV ( while Bells was ? HSV )
• Its 2nd most common cause of the facial
  paralysis
• Complete recovery
• In complete paralysis? 10!
• In incomplete paralysis? 66

?Poor outcome
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• Treatment is with Corticosteroid and Acyclovir
• The main benefit of the corticostroid is
  reduction of postherpetic neuralgia, vertigo and
  acute pain (? its usefulness on recovery of the
  nerve is controvercial)

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Congenital facial paralysis

• Birth trauma ? 78
• Syndromic (Mobius syn., CHARGE,...)
• Surgical exploration and decompression of the
  nerve is rarely
• useful
• Main option is
• muscle transfer.

6th and Mastoid segment of the 7th nerve
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Bilateral Facial Paralysis

• Guillain barre syndrome (9, 10, 7)
• Bells palsy ? 0.3 to 2 of pts
• Idiopathic cranial neuropathies
• Brain stem encephalitis
• BIH
• Syphilis
• Leukemia
• Sarcoidosis, Lyme disease ...

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Traumatic Facial Paralysis

• Most susceptible region distal Labyrinthine and
  Geniculate ganglion
• Surgical timing depends on the onset after injury
  (late, immediate)

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Blunt head truma (sharp nerve cut ? repair in 3
days)

• Surgical time planing
• Immediate paralysis 3 wks after onset
• Delayed paralysis Expectant management and
  corticosteroids will be Okay!, but surgery
  indicates when you see gross disruption of
  fallopian canal in the CT-scan.
• Fisch advocates surgical intervention on the
  basis of ENOG, rather than time of onset of the
  paralysis (...gt90 degeneration within 6 days of
  onset)

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Otitis Media

• AOM, COM, Cholesteatoma
• Most susceptible segment is Tympanic part
• AOM ?IV Abx Myringotomy
• Cholesteatoma ? Removal of the choles. nerve
  decompression without opening the perineurium
• COM ? decide regarding to the degree of
  inflammation

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Thank You!