3. Facial Nerve Palsy/ Paralaysis
• Human face is the focal
point of communication
and expression
• Facial expressions are
formed by the action of
facial muscles
• These muscles are
innervated by the seventh
cranial nerve- Facial Nerve
4. Facial Nerve Palsy
• It is a neurological
condition characterized
by partial or complete
functional loss of the
facial nerve (Cranial
nerve VII)
• Incidence
70cases/100000
5. Facial Nerve
• CN VII is the nerve of second pharyngeal arch
• Complex nerve:
Motor fibers
Sensory fibers
Parasympathetic (visceromotor)
7. Clinical Features of CNVII Palsy
• Loss of forehead wrinkles
• Brow ptosis
• Lagophthalmos (incomplete eye closure)
• Loss of tears/xerophthalmia
• Drooping of malar tissues
• Ptosis of the angle of the mouth
• Deviation of the mouth towards the non-affected
side during smile
• Loss of taste
• Hyperacusis
11. Lower Motor Neurone
• The motor root is
exit with the
nervus
intermedius
(sensory root) in
the ventral surface
of the brainstem
• In between pons
and the medulla
oblangata
VI
VIII
VII
Pons
Medulla
oblangata
13. • Two nerve roots fuse at
the geniculate ganglion
• The cell bodies of the
parasympathetic nerve
fibers are located in the
ganglioan
14. • Enters the posteromedial
surface of the parotid gland
• Travels in between the
superficial and deep lobe of
the parotid gland
• Divide into temporofacial
and cervicofacial divisions
• Five terminal branches
15.
16.
17.
18. UMN palsy LMN palsy
Upper face is intact Both upper and lower face is affected
Emotional movements are intact in
unilateral cases
Emotional movement is lost
Bell’s phenomenon is absent Bell’s phenomenon is present
No atrophy of the facial muscles Atrophy of the facial muscles
Taste sensation is retained Taste sensation is lost
Corneal reflex is intact Corneal reflex is lost
Contralateral hemiplegia Ipsilateral hemiplegia
19. Causes of UMN Palsy
• Stroke in the middle cerebral artery territory
• Multiple sclerosis
• Subdural Haemorrhage
• Intracranial neoplasia
• Trauma
• Encephalitis
21. Idiopathic/Bell’s Palsy
• Incidence 10-40/100000
• Diagnosis of exclusion
• Commonly presents as LMN lesion and
unilateral involvement
• Thought to be related with a viral prodromal
period
22. Trauma
• Fractures of petrous part of the temporal bone
• Direct injury to the facial nerve branches
Crush injury
Laceration
Stretching
Compression
• Iatrogenic- Parotid surgery
Mastoid surgery
25. Neuroprexia
• Mildest injury
• Segmental demyelination may be present
• Local conduction block at the site of injury
• But conduction is intact in the proximal and
distal sites to the injury
• Full functional recovery to be expected within
few days or weeks
27. • Wallerian degeneration occur distal to the site
of injury
• Regeneration occur via axonal sprouting
• Rate – 1mm/day or 1inch/month
• Rate of regeneration can be monitored by the
presence of Tinel sign
28. Diagnosis
• Neuroprexia and axonotmesis can be
diagnosed only after observing the recovery of
the nerve
• If full recovery is occurred within the first 3
months- Neuroprexia
• If recovery is full but at a rate of 1 inch/ month
with the presence of Tinel sign- Axonotmesis
30. • Endoneurial injury will produce scar tissue
• Axon must regenerate through the scar tissue
• Incomplete regeneration
• Injury to the basal lamina of the schwann cell
may cause mismatching of the regenerating
fibers to inappropriate distal receptors
31. • The epineurium is intact
• Therefore injured nerve fibers regenerate
within the fascicle
• Motor and nerve fibers which are in close
contact within the fascicle may produce
abnormal motor and sensory nerve following
recovery
• Recovery rate 1 inch/ month
32. • Recovery pattern can range from complete
recovery to very minimal recovery
• Advancing Tinel sign
34. • Caused by severe stretch or traction
• Intraneural scarring may blocks the regrowing
axons from reaching their destination
• The Tinel sign may present at the site of injury
but no progression will be noted distal to the
injury
• Spontaneous nerve recovery is impossible
without a nerve graft or nerve conduit
• Observation for 3 months is recommended
35. Neurotmesis
• Complete transection of
the nerve
• Most severe type of injury
• Usually associated with
open traumatic injuries
therefore initial diagnosis
is easier
39. Diagnosis of FNP
• History
• Onset
• Duration
• Progression
• H/O head Injury
• Recurrence
• Examination- secondary causes, facial muscle
movement
40. Assessment
• Proper assessment of facial nerve palsy is
important to provide patient counseling and
the treatment
• House and Brackmann scale – to assess the
degree of facial palsy
41.
42. Specific Investigations
• Topodiagnostic testing
• Schirmer’s test for lacrimation
• Stapedial reflex testing
• Taste testing
• Sialometry
• Electroneurography
• Electromyography
These tests should be done at least 10days after the
injury
• Any response above 10% indicates the possibility of
spontaneous reaction
• Additional Ix- CT, MRI
43. Management of FNP
• Goals:
– Restoration of symmetry in upper, middle and
lower face
– Achieve oral and eye closure
• Modification of the affected side or normal
side or both
• Surgical management (Static and dynamic)
• Non- surgical management
44. Treatment Consideration
• Etiology
• Severity
• Duration of the FNP- >2 years motor end
plates degradation
• Age and Comorbidities of the patient
• Patient’s expectations
45. Management of Idiopathic FNP
• Temporary management is appropriate as spontaneous
recovery is expected – Conservative management
• Corticosteroids – recommended by American
Association of Otolaryngology- Head and Neck
Surgery Foundation
• Antiviral drugs- the role is not clear
• Observation
• Topical ocular therapy
• Physical therapy
• Surgical decompression- contraversial
However, the management is remains contraversial
46. Management of Intratemporal nerve
Injury
• Surgical exploration if immediate complete paralysis
present
• definitive Mx will be planned according to the
operative findings
• Decompression- indicated when nerve impingement
due to bony spiclues, contusion, streching, intraneural
haematoma
• Perineural Sheath incision for intraneural haematoma
• Delayed partial paralysis- high dose steroids
47. Surgical Management
• Dynamic Procedures to reanimate the face (correct
asymmetry at rest & function)
• Primary Neurorraphy
• Interpositional Nerve graft
• Nerve transfer
• Muscle transfer
• Free tissue flaps with microvascular anastomosis
• Static Procedures (correct asymmetry at rest)
• Static slings
• Weights
• Tissue rearrangement
48. • Complete transection- primary neurorraphy
– Fine sutures
– Fibrin glue
• Interpositional nerve graft may be indicated if the nerve
length is inadequate for primary neurorraphy
• Donor sites for interpositional nerve graft
Greater auricular nerve
Sural nerve
49. Preparation of the Nerve
• Copious irrigation
• Appropriate antibiotics
• Identification of the proximal and distal ends
of the nerve
• Ragged edges should be freshened
• Best outcome is achieved when there is
tension-free coaptation
52. Surgical techniques for correction of ectorpion
• Lateral tarsal strip
canthopexy
• Lateral transorbital
canthopexy
• Medial canthopexy
53. Dynamic reanimation of the eye
Nerve transfer
• Cross facial nerve graft
• Hypoglossal nerve transfer
Muscle transfer
• Temporalis
• Frontalis
• Free muscle flap
54. Brow ptosis
• Brow lift surgery
(static)
– Open brow approach
– Endoscopic approach
• Adjunctive procedures
to control the
hyperactivity on the
contralateral brow
55. Midface
• Alleviate nasal obstruction
– Suturing
– Suspension sling to nasolabial
fold
• Counteract the forces of
gravity on the malar tissue
– Extended minimal access
cranial facelift (MACS)
(Verpaele et al)
– Mobilization of the sub-
orbicularis oculi fat and the
periosteum (Elner et al)
57. Lower face
• Static slings suspended
from the zygomatic arch
or deep temporal fascia
– Fascialata
– Gore - Tex
– Alloderm
• Extended MACS lift
• Lower lip reanimation
with palmaris longus
tendon transfer (dynamic)
60. Cross facial nerve graft (CFNG)
• First introduced by Scaramella
• Nerve injury should be occurred within 2 years
• Motor end plates should be intact
• Intact peripheral branches of the facial nerve on
the contralateral side can be used to innervate
paralyzed hemi face
• Risks: disturbing the non paralyzed facial nerve
• Prevention: nerve mapping
transfer non-dominant branches
61. • The outcome is unpredictable due to the long distance
axons must travel to their targets, while the muscles
continue to atrophy
• ‘Babysitter’ procedure introduced by Terzis &
Konofaos
• Involving partial hypoglossal nerve transfer
– For rapid neural input
– to prevent loss of motor end plate
64. Masseteric Nerve
• Good candidate
– Good size match
– Adequate length
– Easy dissection
– Less impact on
masticatory function
• High success rate
• Rapid recovery compared to
CN XII
69. Conclusion
• Facial nerve palsy is a clinical sign and not a
disease
• Therefore proper evaluation and treatment plan is
mandatory
• Operative treatment of facial nerve palsy is
remains a challenging problem
70. References
1. Seneviratne SO, Patel BC. Facial Nerve Anatomy and Clinical
Applications. [Updated 2020 Jan 24]. In: StatPearls [Internet]
2. Kosins AM, Hurvitz KA, Evans GR, Wirth GA. Facial paralysis for the
plastic surgeon. Can J Plast Surg. 2007;15(2):77‐82.
doi:10.1177/229255030701500203
3. Gordin E, Lee TS, Ducic Y, Arnaoutakis D. Facial nerve trauma:
evaluation and considerations in management. Craniomaxillofac Trauma
Reconstr. 2015;8(1):1‐13. doi:10.1055/s-0034-1372522
4. Chopan, M., Buchanan, P. J., & Mast, B. A. (2019). The Minimal Access
Cranial Suspension Lift. Clinics in Plastic Surgery.
5. Hellebrand MC, Friebe-Hoffmann U, Bender HG, Kojda G, Hoffmann
TK. Das Mona-Lisa-Syndrom--die periphere Fazialisparese in der
Schwangerschaft [Mona Lisa syndrome: idiopathic facial paralysis during
pregnancy]. Z Geburtshilfe Neonatol. 2006;210(4):126-134.
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