Paralysis of The Facial Nerve AC

Literature Reading
Paralysis of The Facial

Nerve
Presentant : Achmad P
Authors : dr. Sally Mahdiani, M Kes., SpTHT-KL (K)
D E PA R T M E N T O F O T O R H I N O L A R Y N G O L O G Y- H E A D & N E C K S U R G E R Y
FA C U LT Y O F M E D I C I N E PA D J A D J A R A N U N I V E R S I T Y
H A S A N S A D I K I N G E N E R A L H O S P I TA L
BANDUNG
2016
1
INTRODUCTION
Acute facial palsy is a common diagnostic
problem encountered by the otolaryngologist,
but its presentation often provokes
consternation on the physician's part.
Vrabec JT, Lin JW. Acute Paralysis of the Facial Nerve, Baileys Head & Neck Surgery, Fifth edition, Lippincott
William&Wilkin, 2014, p.2503-2517
Epidemyology
Insidence
30 : 100.000 people per
years
Chang et al: Bells Palsy (54,9%)
Infection (26,%), Trauma (5,9%),
Iatrogenik (2,0%) , mass (1,8%)
Left = right
Anatomy Facial nerve
Compone
nt
Complex
motor
sensory
nerve
Parasympath
etic
ANATOMY
General visceral
efferent fibers
parasympathetic
system
visceral afferent
fibers
lacrimal and palatine glands

parotid gland
submandibular and sublingual
glands
sense of taste from the

sensory receptors on the
anterior 2/3 of the tongue
innervate the auricular,

special visceral posterior
belly of the
efferent fibers
digastric, stylohyoid, and
platysma muscles and
the superficial facial
musculature
anatomy
Intra Cranial
MEATA
L
Intra Temporal
LABIRI
N
TYMPHANY
MASTOID
Extra Temporal
INTRAKRANIAL
INTRATEMPORA
L
INTRATEMPORAPOlL
Meatal
Internal auditory canal

(IAC)
13 15 mm
Zero branches
Anatomy of the facial nerve

Labyrinthin
e
IAC to geniculate ganglion

3-4mm
Three branches from geniculate
ganglion
10

Tympanic
Geniculate ganglion to pyramidal

eminence
8-11mm
Zero branches
11

Mastoid
Pyramidal eminence to stylomastoid foramen

10-14mm
Three branches : N stapedial, chorda tymphany, n
auricularis
12

Extratempor
al
Stylomastoid foramen to major

branches
15-20mm
13
Sunderland Nerve Injury Classification
14
Sunderland Nerve Injury Classification
ASSESSMENT
History
Onset
Duration
Rate
of progression
Recurrent or familial
Associated symptoms
Major medical illness of
previous surgery
16
ASSESSMENT
Physical examination
Complete
head and neck

evaluation
Microscopic otoscopy
Cranial nerve assessment
Palpation or parotid gland and neck
Neurologic evaluation
To express paresis or paralysis, it is
beneficial to have the patient
maximize facial movement in all
branches
17
ASSESSMENT
Physical examination
wrinkled m. frontalis
Eye closing m. orbikularis
okuli & sphincter fissura
palpebra
Mouth closing m.orbikularis
oris & sphincter oral
Smiling m. buccinators
Forehead
18
PERIPHERAL LESION
19
CENTRAL LESION
20
Level Of IMPAIRMENT
Level of impairment
Signs
Diagnosis
Supranuclear
Good tone, intact upper face, presence Cerebrovascular accident,

of spontaneous smile, neurologic trauma
deficits
Nuclear
Involvement of the VI and VII cranial Vascular

or
neoplastic,
nerves, corticospinal tract signs
poliomyelitis,
multiple
sclerosis, enchepalitis
Angle
Involment of vestibular and cochlear Neurinoma,

meningioma,
portions of the VIII cranial nerve (facial fracture,
cholesteatoma,
nerve, particularly taste, lacrimation arachnoid cyst
and salivation may be altered); the V
and later IX, X and XI cranial nerves
may become impaired
Geniculate ganglion
Facial paralysis, hypercusis alteration Herpes

zoster
oticus,
of lacrimal,salivation and taste
fracture,
bells
palsy,
cholesteatoma, neurinoma,
arteriouvenous
malformation, meningioma
Tympanomastoid
Fasial
paralysis,
alternation
in Bells palsy, cholesteatoma,
salivation and taste, lacrimation intact
fracture, infection
Extracranial
Facial paralysis (usually a branch Trauma,

tumor,
parotid
is spared), salivation and taste carcinoma,
pharyngeal
intact, deviation of jaw to normal carcinoma
side
ASSESSMENT
Laboratory studies
Pure-tone
and speech audiometry

Electrophysiologic tests
Nerve excitability test (NET)
Maximal stimulation test (MST)
Electroneurography (ENG)
Electromyography (EMG)
Radiographic studies
Computed tomography
Magnetic resonance imaging
24
DIFFERENTIAL
DIAGNOSIS
Infeksi
-Bells
palsy
- Herpes
zoster
otikus
- OME
- OMSK
- OE
maligna
- Lyme
Trauma
- # tl.
Temporal
- Trauma
lahir
- Kontusi
- Iatrogenik
Neoplasia
Kolesteato
ma
- Glomus
jugulare
- Ca
Meningiom
a
- Leukemia
Histiositosi
s
Kongenita
l
- trauma
kompresi
- Paralisis
bibir bawah
- Sindroma
Mobius
Idiopatik
- Paralisis
fasialis
rekuren
- Sindroma
Melkersson
Metabolik
&
Sistemik
Sarkoidosis
- GBS
- Penyakit
otoimun
26
Bells Palsy
Most
common acute facial paralysis

Incidende 30 & 45 cases per 100.000 per year
Etiology idiopathic
HSV infecting agent in Bell palsy
Pathophysiology Impaired axoplasmic flow
from edema of facial nerve within fallopian
canal
Rapid onset < 48 hours
27
Bells Palsy
May
be associated with acute neuropathies of

cranial nerves V- X
Pain or numbness affecting ear, mid-face,
tongue and taste disturbances
Recurrences are more likely (2.5x) in patients
with family history, immunodeficiency or
diabetes
28
Bells Palsy
Treatment
Corticosteroid taper 1mg / kg / day for 10 days

Prednison 450 to 500 mg administered in divided doses
over 7 to 10 days
Antivirals within the first 72 hours
Valacyclovir 1000 mg three times daily for 7 days.
Famciclovir 1500 mg daily for7 days
Facial nerve decompression
Progression to > 90% degeneration on ENOG
Performed before irreversible injury to the
endoneural tubules occurs (two weeks), will allow
for axonal regeneration to occur
29
Herpes Zoster Oticus

(Ramsay Hunt syndrome)
10-15% of acute facial palsy cases

Acute facial paralysis, severe ear pain, a vesicular eruption
of the external auditory canal and concha
Associated symptoms hearing loss (SNHL) and vestibular
dysfunction
30
Herpes Zoster Oticus

(Ramsay Hunt syndrome)
Treatmen
t
Oral antivirals
Acyclovir 5x800mg (7-10 days)

Valacyclovir 1000 mg tid for 7 days
Famciclovir 500 mg tid for 7 days
Steroid same doses as in Bell Palsy
Management of herpes zoster oticus includes intervention directed

at the underlying viral infection and associated complications.
Acyclovir has proven to be of benefit in treatment of herpes zoster
infections, demonstrating reduction in pain and shortening time
to resolution of skin lesions.
31
Otitis media
Acute otitis media ---Incidence 1 : 20.000 cases

Chronic otitis media, cholesteatoma ---- suggesting
possible ischemic nerve injury
Operative management --- myringotomy and tube
CT recommended to evaluate the fallopian canal before
surgery
Tympanomastoid surgery
32
Otitis media
OTITIS MEDIA AND FACIAL PALSY
Acute SOM
OME
Chronic otitis
media
Mastoiditis
Infection involving the fallopian canal

Inflamation and neural edema
Immediate treatment : Eradicating the infection

33
Trauma
Facial
nerve injuries occur in a variety of ways,

including blunt or penetrating trauma and
iatrogenic harm.
Management differs according to extent of injury,
though the severity of the injury is not always
easy to establish.
Temporal bone fractures the most common
cause of traumatic injury to the facial nerve
34
Trauma
Temporal bone fractures
Longitudinal fractures
80% incidence but 10-20% with facial nerve
injury
Transverse fractures
20% incidence, but 50% with facial nerve
injury
Most common site of fracture
Perigeniculate region
35
MANAGEMENT OF TRAUMATIC INJURIES WITH

COMPLETE FACIAL NERVE PARALYSIS
Vrabec JT, Lin JW. Acute Paralysis of the Facial Nerve, Baileys Head & Neck Surgery, Fifth edition,
Lippincott William&Wilkin, 2014, p.2503-2517
36
Facial palsy in the newborn

Trauma may be evident by facial
contusion, ecchymosis over the mastoid
or course of the extracranial nerve, or a
hemotympanum use of forceps
Congenital palsy most commonly
present as a unilateral weakness of the
lower lip and can be associated with
other anomalies.
Kobayashi found no relationship of this
limited form of palsy to the use of
fetotoxic drugs, rubella, birth trauma, or
hereditary factors.
37
Thank You
39

Paralysis of The Facial Nerve AC

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Literature Reading

Paralysis of The Facial

Authors : dr. Sally Mahdiani, M Kes., SpTHT-KL (K)

30 : 100.000 people per

Anatomy Facial nerve

lacrimal and palatine glands

sense of taste from the

innervate the auricular,

Internal auditory canal

Anatomy of the facial nerve

IAC to geniculate ganglion

William&Wilkin, 2014, p.2503-2517

Anatomy of the facial nerve

Geniculate ganglion to pyramidal

Anatomy of the facial nerve

Pyramidal eminence to stylomastoid foramen

Anatomy of the facial nerve

Stylomastoid foramen to major

William&Wilkin, 2014, p.2503-2517

Sunderland Nerve Injury Classification

Sunderland Nerve Injury Classification

head and neck

Good tone, intact upper face, presence Cerebrovascular accident,

Involvement of the VI and VII cranial Vascular

Involment of vestibular and cochlear Neurinoma,

Facial paralysis, hypercusis alteration Herpes

Facial paralysis (usually a branch Trauma,

and speech audiometry

common acute facial paralysis

be associated with acute neuropathies of

Corticosteroid taper 1mg / kg / day for 10 days

Herpes Zoster Oticus

10-15% of acute facial palsy cases

Herpes Zoster Oticus

Acyclovir 5x800mg (7-10 days)

Management of herpes zoster oticus includes intervention directed

Acute otitis media ---Incidence 1 : 20.000 cases

Infection involving the fallopian canal

Immediate treatment : Eradicating the infection

nerve injuries occur in a variety of ways,

MANAGEMENT OF TRAUMATIC INJURIES WITH

Facial palsy in the newborn

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