Facial Paralysis Lecture Ready2

Prof.
Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
‫بسم الله الرحمن الرحيم‬
‫ومن‬ ‫يؤتى الحكمة من يشاء‬

‫خير‬ ‫يؤت الحكمة فقد أوتى‬
‫اكثيرا‬
‫صدق الله العظيم (البقرة ‪)269‬‬
‫الحكمة‪ :‬القدرة على الفهم و التمييز‬

‫)و الصابة فى القول والفعل (الطبرى‬
Facial nerve paralysis
by
M. Hisham Hamad
Prof. Otolaryngology
Tanta University
Prof. Hisham Hamad

Problem solving and
MCQ Questions
Prof. Hisham Hamad

•What is the lesion?
•Side)Rt or Lt(
•Site )U or lower(
Prof. Hisham Hamad

• This gentleman
Problem solving
presented with right
severe otalgia and
drippling of saliva
from the right side
of the mouth with
collection of food in
the right cheek
during meals. No
other associated
symptoms or sign
were noted.
• What is the most

probable
diagnosis?
Prof. Hisham Hamad

• This gentleman is 50
Problem solving
ys old presented with
one day history of “my
face isn’t moving”
– Occurred overnight
– No ear pain, previous
viral illness
– No hearing loss
– No prior history, no
family history
– No other associated
symptoms
• 4 weeks he started to
feel some movement
in his face.
Prof. Hisham Hamad
• Recurrent Facaial paralysis
occurning few days after onset of
acute otitis media denotes
A.Bulging tympanic membrane

B.mastoiditis
C.Congenital anomaly of the ear
D.Immunodefiency
Prof. Hisham Hamad

• Bells balsy is commonly treated
with:
A. antihistaminic and steroids
B. antihistaminic and antiviral
C. antiviral And steroids
D. antibiotic and steroids
Prof. Hisham Hamad

• Progressive unilateral LMN Facaial
paralysis over more than 3 monthes
without identified aetiology is most
probably due to
A. Bell s balsy
B. Brain tumor in motor area of temporal
lobe
C. Acoustic nerve neuroma
D.Malignant otitis externa
Prof. Hisham Hamad

Anatomy
origin
3 nuclei
motor
sup salivary
T solitarius
Mixed nerve
Gen Motor
Secretomotor
Gen Sensory
Sp sensory )taste(
Prof. Hisham Hamad

Anatomy
origin
3 nuclei
motor
sup salivary
T solitarius
Mixed nerve
Gen Motor
Secretomotor
Gen Sensory
Sp sensory (taste)
Prof. Hisham Hamad

Anatom
y
distributio
n
Mixed nerve
General Motor
Secretomotor
General Sensory
Special sensory )taste(
Prof. Hisham Hamad

Anatom
y
Mixed nerve
Motor
muscles of
facial expression
Prof. Hisham Hamad
Anatom
y
Mixed nerve
Secretomotor
lacrimal gl
submandibular
sublingual
Prof. Hisham Hamad

Anatom
y
Mixed nerve
Secretomotor
lacrimal gl
submandibular
sublingual
Prof. Hisham Hamad

Anatom
y
Mixed nerve
Special sensory
tase ant 2/3
of tongue
Prof. Hisham Hamad

Anatom
y
Mixed nerve
General sensory
concha & ext canal
Prof. Hisham Hamad

Motor
UMN
pyramidal
bilateral to
upper face
extra-pyramidal
emothional
movement
LMN
Prof. Hisham Hamad
Motor
UMN
pyramidal
bilateral to
upper face
extra-pyramidal
emothional
movement
LMN
Prof. Hisham Hamad
Motor
UMN
pyramidal
voluntary movement
extra-pyramidal
emothional movement
Prof. Hisham Hamad

Motor
UMN
suranuclear
pyramidal
extra-pyramidal
LMN
nuclear
infranuclear
Prof. Hisham Hamad

UMNL # LMNL
Site of lesion
Side of paralysis
Emotional movement
Upper face movement
Type of lesion
Sequallae of paralysis
Bell s phenomenon
Associates
Prof. Hisham Hamad

UMNL # LMNL
Flaccid paralysis
Prof. Hisham Hamad

UMNL # LMNL
Sequallae of
paralysis
Prof. Hisham Hamad

UMNL # LMNL
Prof. Hisham Hamad

Motor lesion
UMN level
supranuclear Δ
extra Δ
LMN
nuclear
CPA
meatal
lanyrinthine
horizontal tympanic
vertical mastoid
SM foramen
peripheral
Prof. Hisham Hamad
Motor
LMN
nuclear
CPA
meatal
Prof. Hisham Hamad

Motor
LMN
nuclear
CPA
meatal
lanyrinthine
Prof. Hisham Hamad

Motor
LMN
nuclear
CPA
meatal
lanyrinthine
Prof. Hisham Hamad

Motor
LMN
nuclear
CPA
lanyrinthine
horizontal tympanic
Prof. Hisham Hamad

Motor
LMN
nuclear
CPA
meatal
lanyrinthine
horizontal tympanic
vertical mastoid
Prof. Hisham Hamad

Motor
LMN
nuclear
CPA
meatal
lanyrinthine
horizontal tympanic
vertical mastoid
SM foramen
Prof. Hisham Hamad

Motor
LMN
nuclear
CPA
meatal
lanyrinthine
horizontal tympanic
vertical mastoid
SM foramen
peripheral
Prof. Hisham Hamad

Motor
LMN
nuclear
CPA
meatal
lanyrinthine
horizontal tympanic
vertical mastoid
SM foramen
peripheral
Prof. Hisham Hamad

Relations &
LMN
branches
nuclear )6 N( th
CPA )cerebellum & N

intermedius & 8TH
N(
meatal )8th N(
LMN branches level

greater petrosal
N to stapedius
chorda tympani
peripheral
Prof. Hisham Hamad
Disorders of the
facial nerve
Motor dysfunction
hypokinetic
hyperkinetic
blepherospasm & facial tics
hemifacial spasm
facial myokymia
focal siezure
synkinesia
tic doulaureux )trigeminal nueralgia(
Autonomic
crocodile tears
sphenopalatine neuralgia
Sensory
herpes zoster otalgia
Bell s palsy taste disturbance
Pathophysiology
Idiopathic
mostly viral
Traumatic
Inflammatory
neoplastic
Prof. Hisham Hamad

Pathophysiology
Neuropraxia
Axontemesis
neurotmesis
Prof. Hisham Hamad

Sunderland classification of
peripheral nerve injury
Neurapraxia
Axonotmesis
Neurotmesis
Pathophysiology
Wallerian
degeneration
Absent in
neuripraxia
Occurs in
axontemesis
neurontesis
Prof. Hisham Hamad

Pathophysiology
Wallerian
degeneration
Absent in
neuripraxia
Occurs in
axontemesis
neurontesis
Prof. Hisham Hamad

Pathophysiology
Neuropraxia
Axontemesis
neurotmesis
Prof. Hisham Hamad

Pathophysiology
Regeneration
Intact sheath
good recovery
Disrupted sheath
failure )residual paralysis + atrophy(
misdirection
to other muscles)synkinesia(
taste to lacrimal gland )crocodile
tears(
parotid fibres to sweat glands
)frey syn
to other axons)short circuiting(
Prof. Hisham Hamad
TESTS OF THE FACIAL
NERVE
Site of lesion)topognostic(
Electrodiagosis
)prognostic(
Prof. Hisham Hamad

TESTS OF THE FACIAL NERVE
Site of lesion)topognostic(
1-G petrosal N
schirmer test
2-N to stapedius
stapedial reflex
3-chorda tympani
a(taste gustometry
b(salivary flow
5-peripheral brabches
segmental facial movement
Prof. Hisham Hamad

Site of lesion)topognostic(
1-G petrosal N
schirmer test
2-N to stapedius
stapedial reflex
3-chorda tympani
a(taste gustometry
b(salivary flow
Prof. Hisham Hamad

Topognostic Test
• Lacrimal
– Schirmer’s Test
• Stapedial reflex
• Taste
• Salivary flow
Electrodiagosis )prognostic(
1-nerve excitability test
3.5 mA difference is significant
2-strength duration curve
normal, partial or denervation curves
3--maximal N stimulation test
4 electromyography
voluntary,fibrillation denervation or
polyphasic reinnervation potentials
5-electroneurography
the most informative
Prof. Hisham Hamad
Prof. Hisham Hamad

TESTS OF THE FACIAL
NERVE
Electroneurography
the most informative
quantitative
Prof. Hisham Hamad

Diagnosis
Paralysed or not?
Where is the
lesion?
How much is
the
degeneration?
What is the
lesion?
Prof. Hisham Hamad
1-Paralysed or not?
Clinical picture
At rest
Voluntary movement
Prof. Hisham Hamad

Clinical picture
At rest
)Due to unoppoesd
pull of active muscles(
Loss of
Forhead whrinkes
Nasolabial fold
Dead wide Eye
Mouth
Dropped angle
Shortened on active
side
drippling from angle
Prof. Hisham Hamad
Clinical picture
Voluntary movement
 During eating
 During talking
 ask him to
Whrinkle
forehead
Raise eyebrow
Close the eye
Show your teeth
Blow your cheek
To whistle
Prof. Hisham Hamad
Clinical picture
During Close the Blow the Show th

voluntary eyes teeth
cheek
movement
Prof. Hisham Hamad

2-Where is the
lesion
UMNL or LMNL
LMNL what level
nuclear
CPA
meatal
at geniculate(
suprapyramidal
infrapyramidal
at stylomastoid F
extratemporal
Prof. Hisham Hamad

UMNL # LMNL
Site of lesion
Side of paralysis
Upper face movement
Type of lesion
Sequllae of paralysis
Prof. Hisham Hamad

2-Where is the
lesion
UMNL or LMNL
LMNL what level
nuclear
CPA
meatal
at geniculate(
suprapyramidal
infrapyramidal
at stylomastoid F
extratemporal
Prof. Hisham Hamad

2-Where is the
lesion
UMNL or LMNL
LMNL what level
nuclear
CPA
meatal
at geniculate(
suprapyramidal
infrapyramidal
at stylomastoid F
extratemporal
Prof. Hisham Hamad

2-Where is the
lesion
UMNL or LMNL
LMNL what level
nuclear
CPA
meatal
at geniculate(
suprapyramidal
infrapyramidal
at stylomastoid F
extratemporal
Prof. Hisham Hamad

2-Where is the
lesion?
topognostic tests
1-G petrosal N
schirmer test
2-N to stapedius
stapedial reflex
3-chorda tympani
a(taste gustometry
b(salivary flow
Prof. Hisham Hamad
2-Where is the
lesion
UMNL or LMNL
LMNL
nuclear )6th N+ hemiplegia
+ all Normal(
CPA )cerebellum+ 8TH N
+ N intermedius(
meatal )No celebellar(
at geniculate)No 8TH N(
tympanic )Normal tearing(
mastoid )Normal tearing & N
AR(
at stylomastoid F )all Normal(
extratemporal )segmental(
Prof. Hisham Hamad
3-How much
degeneration
Degree does not
matter
Incomplete paralysis
always recovers well
Complete paralysis
recovers well
if neuropraxic
if degeneration is
less than 90%
Prof. Hisham Hamad
3-How much
degeneration
Elecrodiagnostic tests
Elecroneurography test
IS THE MOST VALUEBLE
QUANTITATIVE
90 % or less degeneration
denotes poor
recovery
Prof. Hisham Hamad

4-What is the
lesion
Idiopathic ?
Inflammatory
malig OE
AOM, A mastoiditis
ch OM, H zoster
Traumatic
F base, forceps
cut wound
Iatrogenic
brain, ear, parotid
Neoplastic
primary
2ndary
Toxic
metabolic
Prof. Hisham Hamad
4-What is the
lesion
Idiopathic ?
Inflammatory
malig OE
AOM, A mastoiditis
ch OM, H zoster
Traumatic
F base, forceps
cut wound
Iatrogenic
brain, ear, parotid
Neoplastic
primary
2ndary
Toxic
metabolic
Prof. Hisham Hamad
4-What is the
lesion
Idiopathic ?
Inflammatory
malig OE
AOM, A mastoiditis
ch OM, H zoster
Traumatic
F base, forceps
cut wound
Iatrogenic
brain, ear, parotid
Neoplastic
primary
2ndary
Toxic
metabolic
Prof. Hisham Hamad
Complications
Psychological
Drooling
Eye complications
exposure keratitis
infection )up to panophthamitis(
Persistent paralysis
Tics & spasm
Atrophy & contracture
Crocodile tears
Frey syndrome
Prof. Hisham Hamad

Treatment: Avoid complication
Of the cause
Avoid complication
eye
muscle atrophy
residual paralysis
Treat established complications

residual paralysis
crocodile tears $ gustatory
sweating
Prof. Hisham Hamad

Of the cause

antibiotic in malignant OE
Acyclovir if viral )H zoster & Bell s(
myringotomy if early in AOM
mastoidectomy if late in AMO
mastoidectomy if in chronic MO
Treat established complications
Prof. Hisham Hamad

Treatment:
Of the cause Avoid complication
eye
artificial tears & ointment & dark
glasses
tarsorraphy or gold weight
implant
muscle atrophy
adhesive tape
phsiotherapy )passive $ active(
residual paralysis
medically steroid
surgical if more than 90% deg
decompression
reanastonosis
grafting
Treatment: Surgery Guidelines
If partial No surgery

If complete do elecrodiagnosis
tests
till recovery
till 90%
degeneration
 if more than 90% degeneration do
decompression )partial injury(
reanastomosis )complete injury(
nerve grafting )tissue loss(
Treatment: eye
Avoid eye complication
artificial tears
ointment
tarsorraphy
gold weight implant
Prof. Hisham Hamad

Prof. Hisham Hamad
Gold
weight
implanta
tion
Treatment:
Of the cause Avoid complication
Treat established
complications
residual paralysis
reanimation )if irreversible(
dynamic
graft
facio-facial )cross face(
hypoglossal to facial
free micro-neuro-
vascular
static )sling(
facia lata
temporalis muscle
masseter muscle
crocodile tears $ gustatory
Dynamic reanimatiom
facio-facial )cross
graft face(
hypoglossal to facial
Prof. Hisham Hamad
Dynamic reanimatiom
free micro-neuro-vascular
Prof. Hisham Hamad

static reanimatiom
Prof. Hisham Hamad

Bell s palsy
Definition:: idiopathic+ unilateral+ LMNL of the facial
nerve
Aetiolgy:
Idiopathic
Ischeamia
primary )cold(
2ary)viral or autoimmune(
Polymerase chain reaction )PCR( have demonstrated
herpetic infection in most of the ceses. A better term
is viral or herpetic facial paralysis.
Prof. Hisham Hamad

Diagnosis:
Prof. Hisham Hamad

Treatment: prognosis
Prof. Hisham Hamad

Treatment:
No treatment for partial paralysis
Complete paralysis give :
Cortisone
Acyclovir
VD ?? + neurotropic vitamins ??
Surgical decompression if degeneration

exceeds 90%
physiotherapy afterv 2 weeks
dark glasses + eye ointment +adhesive

tapes Prof. Hisham Hamad
Problem solving and
MCQ Questions
Prof. Hisham Hamad

•Side)Rt or Lt(
Prof. Hisham Hamad

•Side)Rt or Lt(
Prof. Hisham Hamad

•Side)Rt or Lt(
Prof. Hisham Hamad

•Side)Rt or Lt(
Prof. Hisham Hamad

• This gentleman
Problem solving
presented with right
severe otalgia and
drippling of saliva
from the right side
of the mouth with
collection of food in
the right cheek
during meals. No
other associated
symptoms or sign
were noted.

probable
diagnosis?
Prof. Hisham Hamad

Problem solving
• This gentleman is 50 ys old
presented with one day history
of “my face isn’t moving”
– Occurred overnight
– No ear pain, previous viral
illness
– No hearing loss
– No prior history, no family
history
– No other associated symptoms
• 4 weeks he started to feel some

movement in his face.

probable diagnosis?
Prof. Hisham Hamad
• Recurrent Facaial paralysis
occurning few days after onset of
acute otitis media denotes
A.Bulging tympanic membrane

B.Mastoiditis
C.Congenital anomaly of the ear
D.Immunodefiency
Prof. Hisham Hamad

•Bells balsy is commonly treated
with:
A( antihistaminic and steroids
B( antihistaminic and
antiviral
C( antiviral And steroids
D( antibiotic and steroids
Prof. Hisham Hamad
•Progressive unilateral LMN Facaial paralysis
over more than 3 monthes without identified
aetiology is most probably due to
•A( Bell s balsy
•B( Brain tumor in motor area of temporal
tempora
lobe
•C Acoustic nerve neuroma
•D( Malignant otitis externa
Prof. Hisham Hamad

1. Most prescribe steroids.
The benefit is controversial.
Conversely, 60mg of
Prednisone for 7-10 days
has only minor risks
2-The prognosis is so poor for

Herpes Zoster Oticus cases
that specialty consultation
is required for patient
satisfaction )that all
possible was done( and for
the PCP's medical legal
protection.
3-Possible Lyme disease in
endemic areas
Prof. Hisham Hamad

Prof. Hisham Hamad

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‫ومن‬ ‫يؤتى الحكمة من يشاء‬

‫الحكمة‪ :‬القدرة على الفهم و التمييز‬

Prof. Hisham Hamad

Prof. Hisham Hamad

Prof. Hisham Hamad

• What is the most

Prof. Hisham Hamad

A.Bulging tympanic membrane

Prof. Hisham Hamad

Prof. Hisham Hamad

Prof. Hisham Hamad

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Prof. Hisham Hamad

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Prof. Hisham Hamad

Prof. Hisham Hamad

Prof. Hisham Hamad

Prof. Hisham Hamad

Prof. Hisham Hamad

Prof. Hisham Hamad

Prof. Hisham Hamad

Prof. Hisham Hamad

Prof. Hisham Hamad

Prof. Hisham Hamad

Prof. Hisham Hamad

Prof. Hisham Hamad

Prof. Hisham Hamad

Prof. Hisham Hamad

CPA )cerebellum & N

LMN branches level

Prof. Hisham Hamad

Prof. Hisham Hamad

Prof. Hisham Hamad

Prof. Hisham Hamad

Prof. Hisham Hamad

Prof. Hisham Hamad

Prof. Hisham Hamad

Prof. Hisham Hamad

Prof. Hisham Hamad

Prof. Hisham Hamad

Prof. Hisham Hamad

During Close the Blow the Show th

Prof. Hisham Hamad

Prof. Hisham Hamad

Prof. Hisham Hamad

Prof. Hisham Hamad

Prof. Hisham Hamad

Prof. Hisham Hamad

Prof. Hisham Hamad

Prof. Hisham Hamad

Treat established complications

Prof. Hisham Hamad

Of the cause

Treat established complications

Prof. Hisham Hamad

If partial No surgery

Prof. Hisham Hamad

Prof. Hisham Hamad