1. THE FACIAL NERVE DR. SAMI ALHARETHY ASSIS. PROF. CONSULTANT-KSU
بسم الله الرحمن الرحيم
THE FACIAL NERVE
DR. SAMI ALHARETHY
ASSIS. PROF. CONSULTANT-KSU

2. Complications of Facial Paralysis
Facial paralysis severely affect:
Normal facial expressions
Mastication
Speech production
Eye protection.

3. Psychological Trauma The most significant complication is the social isolation these patients.

4. Outline
Anatomy
Pathophysiology
Diagnostics
Treatment
Reanimation

5. Facial Nerve Anatomy 10,000 neurons
7,000 myelinated facial expression.
Parasympathetic secretomotor

6. Nuclei(PONS) 4 Ss 1. Solitarius (Taste) 2. Superior salivatory nucleus
3. Spinal nucleus of the trigeminal nerve
4. Seventh motor

7. Solitarius

8. Superior salivatory nucleus

10. FACIAL NERVE FIBERS Motor Secreto-motor Taste Sensory
to the stapedius and facial muscles
Secreto-motor
to the submandibular, sublingual salivary glands and to the lacrimal glands
Taste
from the anterior two thirds of tongue and palate
Sensory
pain, temperature, and touch from the external auditory canal

11. Facial Nerve Segments Intracranial Meatal Labyrinthine Tympanic
Mastoid
Extratemporal
intracranial (cisternal) segment
meatal segment (internal auditory canal) - 8 mm - zero branches
labyrinthine segment (IAC to geniculate ganglion) mm - 3 branches (from geniculate ganglion)
tympanic segment (from geniculate ganglion to pyramidal eminence) mm - zero branches
mastoid segment (from pyramidal eminence to stylomastoid foramen) mm - 3 branches
extratemporal segment (from stylomastoid foramen to division into major branches) mm - 9 branches
(info.med.yale.edu)

12. Facial Nerve Segments Intracranial Meatal Labyrinthine Tympanic
Mastoid
Extratemporal
intracranial (cisternal) segment
meatal segment (internal auditory canal) - 8 mm - zero branches
labyrinthine segment (IAC to geniculate ganglion) mm - 3 branches (from geniculate ganglion)
tympanic segment (from geniculate ganglion to pyramidal eminence) mm - zero branches
mastoid segment (from pyramidal eminence to stylomastoid foramen) mm - 3 branches
extratemporal segment (from stylomastoid foramen to division into major branches) mm - 9 branches
(Lalwani AK, ed. Current Diagnosis and Treatment: Otolaryngology Head and Neck Surgery, 2nd Ed.)
Internal auditory canal (IAC)
7 UP
Zero branches

13. Facial Nerve Segments Intracranial Meatal Labyrinthine Tympanic
Mastoid
Extratemporal
intracranial (cisternal) segment
meatal segment (internal auditory canal) - 8 mm - zero branches
labyrinthine segment (IAC to geniculate ganglion) mm - 3 branches (from geniculate ganglion)
tympanic segment (from geniculate ganglion to pyramidal eminence) mm - zero branches
mastoid segment (from pyramidal eminence to stylomastoid foramen) mm - 3 branches
extratemporal segment (from stylomastoid foramen to division into major branches) mm - 9 branches
IAC to geniculate ganglion
3-4mm
Only segment that lacks arterial anastomosis

14. Facial Nerve Segments Intracranial Meatal Labyrinthine Tympanic
Mastoid
Extratemporal
intracranial (cisternal) segment
meatal segment (internal auditory canal) - 8 mm - zero branches
labyrinthine segment (IAC to geniculate ganglion) mm - 3 branches (from geniculate ganglion)
tympanic segment (from geniculate ganglion to pyramidal eminence) mm - zero branches
mastoid segment (from pyramidal eminence to stylomastoid foramen) mm - 3 branches
extratemporal segment (from stylomastoid foramen to division into major branches) mm - 9 branches
Geniculate ganglion to pyramidal eminence
50% dehiscent
Zero branches

15. Facial Nerve Segments Intracranial Meatal Labyrinthine Tympanic
Mastoid
Extratemporal
intracranial (cisternal) segment
meatal segment (internal auditory canal) - 8 mm - zero branches
labyrinthine segment (IAC to geniculate ganglion) mm - 3 branches (from geniculate ganglion)
tympanic segment (from geniculate ganglion to pyramidal eminence) mm - zero branches
mastoid segment (from pyramidal eminence to stylomastoid foramen) mm - 3 branches
extratemporal segment (from stylomastoid foramen to division into major branches) mm - 9 branches
Pyramidal eminence to stylomastoid foramen
8-14mm

16. Facial Nerve Segments Intracranial Meatal Labyrinthine Tympanic
Mastoid
Extratemporal
intracranial (cisternal) segment
meatal segment (internal auditory canal) - 8 mm - zero branches
labyrinthine segment (IAC to geniculate ganglion) mm - 3 branches (from geniculate ganglion)
tympanic segment (from geniculate ganglion to pyramidal eminence) mm - zero branches
mastoid segment (from pyramidal eminence to stylomastoid foramen) mm - 3 branches
extratemporal segment (from stylomastoid foramen to division into major branches) mm - 9 branches
Stylomastoid foramen to major branches
15-20mm (

18. Anatomy of Facial Nerve
The pathway of the facial nerve is long and relatively convoluted.
So there are a number of causes that may result in facial nerve paralysis

19. CLINICAL MANIFESTATIONS
Paralysis of facial muscles
Asymmetry of the face
Inability to close the eye
Accumulation of food in the cheek
Phonophobia
Dryness of the eyes
Loss of taste

20. Diagnostics History and Physical Examination
Hearing loss or vertigo
Timing
Sudden onset
Evolution over 2-3 weeks
Presence of ear disease
Vesicular eruption
Bilateral
Recurrence
Symmetric audiological function
Absent ipsilateral acoustic reflex

21. Diagnostics History and Physical Examination
Hearing loss or vertigo
Timing
Presence of ear disease
Vesicular eruption
Bilateral
Recurrence

22. Diagnostics History and Physical Examination
Hearing loss or vertigo
Timing
Sudden onset
Evolution over 2-3 weeks
Presence of ear disease
Vesicular eruption
Bilateral
Recurrence
Chronic otitis media
Cholesteatoma

23. Diagnostics History and Physical Examination
Hearing loss or vertigo
Timing
Sudden onset
Evolution over 2-3 weeks
Presence of ear disease
Vesicular eruption
Bilateral
Recurrence
Ramsay-Hunt syndrome

24. Diagnostics History and Physical Examination
Hearing loss or vertigo
Timing
Sudden onset
Evolution over 2-3 weeks
Presence of ear disease
Vesicular eruption
Bilateral
Recurrence
(ent.uci.edu)
Guillain-Barre syndrome
Lyme disease
Intracranial neoplasm

25. Diagnostics History and Physical Examination
Hearing loss or vertigo
Timing
Sudden onset
Evolution over 2-3 weeks
Presence of ear disease
Vesicular eruption
Bilateral
Recurrence
(Rev Bras Otorrinolaringol 2002; 68(5): )
Melkersson-Rosenthal syndrome

26. House-Brackmann Scale
Grade
Appearance
Forehead
Eye
Mouth I
normal II
slight weakness
normal resting tone
moderate to good movement
complete closure
minimal effort
slight asymmetry
III
non-disfiguring weakness
slight to moderate movement
maximal effort IV
disfiguring weakness
none
incomplete closure
asymmetric with maximal effort V
minimal movement
asymmetric resting tone
slight movement VI
asymmetric

27. Diagnostics Radiology
Localize lesion
Computed tomography
Trauma
Mastoiditis
Cholesteatoma
Magnetic resonance imaging (MRI)
Nerve enhancement
Exclude neoplasm
Usually MRI enhancement in labyrinthine segment

28. Diagnostics Topography
Schirmer test → greater superficial petrosal
Stapedial reflex → stapedial branch
Electrogustometry → chorda tympani
Salivary flow → chorda tympani

29. Diagnostics Audiology
Evaluate for pathology of eighth cranial nerve
Bell’s palsy
Symmetric audiological function
Absent ipsilateral acoustic reflex
Retrocochlear pathology
Asymmetrical thresholds
Evaluate for retrocochlear pathology (e.g. neoplasm) with either ABR or MRI.

30. Diagnostics Electrophysiology
Provides prognostic information
Not used for paresis only
Tests
Nerve excitability test (NET)
Maximum stimulation test (MST)
Electroneuronography (ENoG)
Electromyography (EMG)

31. Upper motor lesions spare the upper facial muscles and affect the contralateral lower face
Lower motor lesions affect all the ipsilateral facial muscles

32. BELL’S PALSY Most common diagnosis of acute facial paralysis
Diagnosis is by exclusion

33. PATHOLOGY
Edema of the facial nerve sheath along its entire intratemporal course (Fallopian canal)

34. ETIOLOGY
Vascular vs. viral

35. CLINICAL FEATURES Sudden onset unilateral FP Partial or complete
No other manifestations apart from occasional mild pain
May recur in 6 – 12%

36. PROGNOSIS 80% complete recovery 10% satisfactory recovery
10% no recovery

37. TREATMENT Reassurance Eye protection Physiotherapy
Medications ( steroids, antivirals vasodilators)
Surgical decompression in selected cases

38. SURGICAL MANAGEMENT Debate over years Patients with 90% degeneration
Within 14 days of onset

39. INFLAMMATORY CAUSES OF FACIAL PARALYSIS

40. Facial Paralysis in AOM
Mostly due to pressure on a dehiscent nerve by inflammatory products
Usually is partial and sudden in onset
Treatment is by antibiotics and myringotomy

44. Facial Paralysis in CSOM
Usually is due to pressure by cholesteatoma or granulation tissue
Insidious in onset
May be partial or complete
Treatment is by immediate surgical exploration and “proceed”

46. HERPES ZOSTER OTICUS (RAMSAY HUNT SYNDROME)
Herpes zoster affection of cranial nerves VII, VIII, and cervical nerves
Facial palsy, pain, skin rash, SNHL and vertigo

47. HERPES ZOSTER OTICUS (RAMSAY HUNT SYNDROME)
Herpes zoster affection of cranial nerves VII, VIII, and other nerves
Facial palsy, pain, skin rash, SNHL and vertigo
Vertigo improves due to compensation
SNHL is usually irreversible
Facial nerve recovers in about 60%
Treatment by: Acyclovir, steroid and symptomatic

48. Traumatic Facial Injury
Birth trauma
Iatrogenic
Temporal bone fracture

49. Congenital Facial Palsy
80-90% are associated with birth trauma
% are associated with developmental lesions

50. Iatrogenic Facial Nerve Injury
Operations at the CP angle, ear and the parotid glands

54. Temporal Bone Fracture
Longitudinal
- 80% of Temporal Bone Fractures
% Facial Nerve involvement
Transverse
- 20% of Temporal Bone Fractures
- 50% Facial Nerve Involvement

55. Transverse Fracture

57. Racoon eyes sign

58. Battle's sign

59. Pathology
Edema
Transection of the nerve

60. Management of Traumatic Facial Nerve Injury
If it is delayed in onset, it is usually incomplete and is due to edema
Conservative
If of immediate onset, it is usually complete and due to transection of the nerve
Surgical repair

61. Facial Reanimation
Facial reanimation is a family of different surgical techniques to make one's paralyzed face move more normally.

62. Reanimation Techniques
Are based on:
The cause of the facial paralysis
Type of injury and its location
The duration of deficit.

63. Facial Reanimation Techniques
Broadly classified into:
NEURAL METHODS:
Micro-neurological surgery to re-suture the damaged nerve.
Nerve graft.
Nerve substitution

64. Facial Reanimation Techniques
MUSCULOFASCIAL TRANSPOSITIONS:
Move new muscles and nerves into the face to take the place of the injured facial nerve.
FACIAL PLASTIC PROCEDURES.
PROSTHETICS.

65. Micro-neurological Surgery
Facial nerve repair is the most effective procedure to restore facial function in patients who have suffered nerve damage from an accident or during surgery.
It involves microscopic repair of a nerve that has been cut.
A nerve graft replaces one that has been removed.

66. Nerve Substitution
Is indicated when the nerve cannot be repaired in the conventional manner.
In this procedure, another cranial nerve involved in facial movement is connected to the damaged nerve and takes over its function.

67. Nerve Transposition
Nerve transposition is also known as facial-hypoglossal transfer.
Restores movement to the side of the face that has been paralyzed.
With the stump of the 12th nerve hooked up to the end of the 7th nerve, the face will move when the tongue is moved.

68. Hypoglossal Facial Nerve Transfer
Entire hypoglossal nerve transected
40% segment of nerve secured to lower division.
Hypoglossal nerve reflected superiorly

69. Hypoglossal Facial Nerve Transfer
Jump graft modification
Reflection of the facial nerve out of the mastoid bone.

70. Temporalis Transfer
Involves taking a 1-2 cm band of the temporalis muscle.
Rotating it from the temple region, over the cheek bone and down, to attach to the corner of the mouth.
When it is appropriately secured, the act of biting down will result in elevation of the corner of the mouth toward the cheekbone, just as in smiling.

71. Temporalis Muscle Transfer

72. Temporalis Transfer

73. Digastric Muscle Transposition

74. Gracilis Graft For Facial Paralysis

75. Combination Muscle And Nerve Graft
In a combination muscle and nerve graft, two procedures are performed several months apart.
Free muscle tissue is grafted from the leg to the face following a cross-facial nerve graft.
The nerve graft becomes the nerve supply for the healthy, transplanted muscle.

76. Rehabilitation of the Paralyzed Eye
The eyebrow can be repositioned by performing a unilateral brow lift, and matching the brow height with the other side.
The eyelids can be addressed using implantable eyelid springs so that gravity assists with eye closure.
Using lid gold weights
Canthoplasty

77. Lid Gold Weights.

78. Nasal wall Suspension

79. Static Facial Suspension
Static Facial Suspension is used to lift the corner of the mouth so that balance is restored to the face and drooling out of the mouth is helped.

80. Cosmetic Surgeries Cosmetic surgeries such as: Brow-lifts Face-lifts
Muscle shortening
Removal of excess upper eyelid skin
Static slings
Improve appearance, but will not improve muscle function.

81. What do you think? What is the most likely diagnosis?
Mention 2 common causes?

82. 36 years old man with RTA: What is your diagnosis?
Mention 2 clinical findings?

83. 34 yrs old with LMN facial paralysis.
A- what is your diagnosis?
B- what is your management?

84. 24 yrs old man involved in RTA.
A- what is your diagnosis?
B- mention 2 other clinical findings?

85. THANK YOU