1. JC Fleming
ENT Specialty Registrar

2.  Broad spectrum of pathologies
 Severe functional and psychological
consequences
 Rapid investigation and treatment of
reversible causes vital
 Knowledge of anatomy vital to narrow
differential diagnoses

3.  Palsy: Complete or partial muscle paralysis,
often accompanied by loss of sensation and
uncontrollable body movements or tremors
 Paresis: Muscular weakness
 Paralysis: Complete loss of muscle function

4.  Brainstem Nuclei
 Motor root emerges from lower pons
 Intracranial
 Runs from brainstem to Internal auditory canal
 Joined here by Nervus Intermedius
 Intratemporal
 From Internal auditory meatus to stylomastoid
foramen
 Labyrinthine segment is narrowest segment of
facial nerve course – susceptible to compression
 Extratemporal
 Divides within parotid gland (TZBMC)

5. Cranial nerve VII 7, with facial canal highlighted
Image:Cranial_nerve_VII.svg by Patrick J. Lynch, medical
illustrator

6.  right-sided middle ear space with the
external ear canal, eardrum (tympanic
membrane) and hearing bones (ossicles)
removed
Right-sided middle ear space with the external ear canal, eardrum (tympanic membrane) and
hearing bones (ossicles) removed.
The facial nerve is seen to pass horizontally in a path superior to the middle ear, and then
turn in an inferior direction and then pass vertically posterior to the middle ear.

7. Extratemporal course of the facial nerve
Courtesy of Patrick J. Lynch, medical illustrator

8.  Neuropraxia
 Compression injury; conduction block; complete
recovery likely
 Axonotmesis
 Axonal injury but endoneurium preserved; axon
regeneration 1mm/day
 Neurotmesis
 Nerve transection

9.  History
 Onset
 Progression
 If no recovery after 4-6 weeks, rule out neoplasm
 Relevant PMH
 Recent infection
 Trauma
 Surgery
 Syphilis/HIV/TB history
 Toxin exposure
 Associated features
 Fever
 Otalgia
 Vertigo
 Family History
 Drug History

10.  Full head and neck examination
 Full cranial nerve examination
 If other neuropathies present, suspect central or
systemic cause
 Sparing of forehead movement ->central
lesion (UMN) due to cross-innervation
 If partial localised palsy, suspect parotid
disease

11.  GRADE I-VI
 Detailed grading system
 Important for prognosis and to monitor recovery
Remember:
 Grade I: Normal function
 Grade VI: Total paralysis
 Grades II-III: complete eye closure possible
 Grades IV-V: incomplete eye closure

12.  Bloods
 Look for specific causes (see next slide!)
 Electrophysiology
 ENoG, EMG
 IMAGING
 CT (intratemporal portion), MRI
 Schirmer test: look for decrease in lacrimation, due to
injury of greater superficial petrosal nerve (preganglionic
parasympathetic fibres to lacrimal gland)
 Stapedial reflex
 Electrogustometry
 RARELY USED

13.  Many! Apply surgical sieve e.g. TIN CAN MED DIP
 Or KITTENS
 K (c)ongenital
 Mobius syndrome; myotonic dystrophy
 I nfection and idiopathic
 Bells palsy; Ramsay-Hunt; Otitis media; Meningitis; Lymes disease; TB;
HIV; Syphilis
 T oxins and trauma
 Lead poisoning; surgery; temporal bone trauma
 T umour
 Parotid; acoustic neuroma; Meningioma; Glioma; cholesteatoma
 E ndocrine
 Diabetes mellitus; hyperthyroidism
 N eurologic
 Guillain-Barre; MS; CVA
 S ystemic
 Sarcoidosis; amyloidosis

14. By James Heilman, MD (Own work) [CC-BY-SA-3.0
(www.creativecommons.org/licenses/by-sa/3.0) or GFDL
(www.gnu.org/copyleft/fdl.html)], via Wikimedia Commons

15.  Most common cause of paralysis
 Paralysis (2/3) or paresis (1/3) of face
 Sudden onset
 Absence of intracranial or ear disease
 Often:
 Viral prodrome
 Dysgeusia (chorda tympani)
 Hyperacusis (stapedius)
 Cause:
 HSV, microcirculatory failure implicated
 70% full recovery by 6 months
 Degree of paralysis prognostic
 Treatment: Corticosteroids, Eye protection, (oral
antivirals [controversial])

16.  CNVII palsy accompanied by a herpes zoster
induced erythematous vesicular rash on the
ear or in the mouth.
 Worse prognosis than Bell’s
 Management: Antivirals, corticosteroids and
eye protection

17.  Severe functional and cosmetic outcomes
 Wide range of causes
 REMEMBER eye protection
 Bell’s palsy most common BUT diagnosis of
exclusion
Symptoms progressive/non-resolving after 4-
6 weeks, rule out underlying malignancy