1 / 73

Facial Nerve Paralysis

Facial Nerve Paralysis. พ.ท. ขจรเกียรติ ประสิทธิเวชชากูร. Outlines. Anatomy Classification Evaluation Electrodiagnosis testing Management Bell ’ s palsy ,Ramse Hunt syndrome Temporal bone fracture. Anatomy of Facial nerve. The facial nerve contains approximately 10,000 fibers

dana
Télécharger la présentation

Facial Nerve Paralysis

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Facial Nerve Paralysis พ.ท. ขจรเกียรติ ประสิทธิเวชชากูร

  2. Outlines • Anatomy • Classification • Evaluation • Electrodiagnosis testing • Management • Bell’s palsy ,Ramse Hunt syndrome • Temporal bone fracture

  3. Anatomy of Facial nerve • The facial nerve contains approximately 10,000 fibers • 7000 myelinated fibers innervate the muscles of facial expression, stapedius muscle, postauricular muscles, posterior belly of digastric muscle, and platysma • 3000 fibers form the nervus intermedius (Nerve of Wrisberg) • sensory fibers (taste) from the anterior 2/3 of the tongue • taste fibers from soft palate via palatine and greater petrosal nerve • parasympathetic secretomotor fibers to the parotid, submandibular, sublingual, and lacrimal gland

  4. Anatomy of Facial nerve 1) Intracranial part • Supranuclear segment • Nuclear segment • Infranuclear segment • Cerebellopontine angle • Internal acoustic canal • Labyrinthine segment • Tympanic segment • Mastoid segment 2) Extracranial part

  5. Supranuclear segment • Cerebral cortex  Corticobulbar tract  Facial nucleus (pons) • Upper face  crossed & uncrossed • Lower face  crossed only

  6. Nuclear segment • Facial motor nucleus • lower 1/3 of Pons • abducent nucleus • Out from brain stem at pons recess between olive andinferior cerebellar peduncle

  7. Nervous intermedius • Parasympathetic secretory fibers arise from superior salivatory nucleus • These preganglionic fibers travel to the submandibular ganglion via the chorda tympani nerve to innervate the submandibular and sublingual glands • And to sphenopalatine ganglion via greater superficial petrosal nerve to innervate lacrimal, nasal, and palatine gland

  8. Nervous intermedius • Secretory fibers of lesser superficial petrosal nerve tranverse tympanic plexus, synapse in otic ganglion, and travel via auriculotemporal nerve to innervate parotid gland • Taste fibers from anterior 2/3 of tongue reach geniculate ganglion via chorda tympani nerve and from there travel to the nucleus of the tractus solitarius

  9. Submandibular ganglion Submandibular gland

  10. Infranuclear segment • Cerebellopontine angle • Internal acoustic canal • Labyrinthine segment • Tympanic segment • Mastoid segment

  11. Cerebellopontine angle • The facial nerve and nervus intermedius exit the brain stem at the pontomedullary junction and travel with CN VIII to enter the internal acoustic meatus

  12. Internal acoustic canal • Motor facial nerve (medial) • Nervus intermedius (between) • Acoustic nerve (lateral)

  13. Labyrinthine segment • Fallopian canal • Shortest & Narrowest part • Temporal bone • Facial nerve enter fallopian canal until middle ear • First genu • Geniculate ganglion • Branches • Greater superficial petrosal nerve lacrimal gland • Lessor superficial petrosal nerve parotid gland

  14. Tympanic segment • Firstgenu  above oval window  stapes • Second genu beyond middle ear • Out of cranium through stylomastoid foramen

  15. Mastoid segment • Stylomastoid foramen • Branches • Motor nerve to stapedius muscle • Chorda tympani nerve betweenmalleus andincus • secretomotor : Submandibular & Sublingual gland • taste fiber : anterior 2/3 of tongue

  16. Extracranial segment • Posterior auricular nerve : auricularis, occipitalis and sensation at auricular, post auricular area • Branch to posterior belly of digastric muscle and stylohyoid muscle • Temporal branch: muscle above zygoma • Zygomatic branch : orbicularis occli • Buccal branch : buccinator and upper lip • Marginal mandibular branch : orbicularis oris andlower lip • Cervical branch : platysma

  17. Physiology • Efferentfibers: from the motor nucleus innervate muscles of facial expression, post-auricular, stylohyoid, posterior digastric, and stapedius muscles • Efferentfibers : ANS (preganglionic parasympathetic fiber) • sphenopalatine ganglion to lacrimal glands and mucinous glands of nose • submandibular gangliontosubmandibular and sublingual glands

  18. Physiology • Afferentfibers convey taste from anterior two-thirds of tongue to nucleus tractus solitarius via lingual nerve, chorda tympani, and nervus intermedius. • Afferent fibers mediate sensation from posterior external auditory canal, concha, ear lobe, and deep parts of face

  19. Classificationsof facial nerve injury Seddon classification of nerve injury • Neuropraxia • Axonotmesis • Neurotmesis

  20. Classifications Sunderland classification of nerve injury 1° damage = Compression 2° damage = Interruption of axoplasm 3° damage = Disruption of myelin 4° damage = Disruption of perineurium, myelin and axon 5° damage = Transection of nerve

  21. Sunderland Classification of nerve injury

  22. Nerve injury • neurapraxia ~ Sunderland grade 1 • axonotmesis ~ Sunderland grade 2-3 • neurotmesis ~ Sunderland grade 4-5

  23. Degeneration • Interruption of the continuity of the axon separates the distal axon from its metabolic source, the neuron or cell body • Wallerian degeneration of the distal axon and myelin sheath begins within 24 hours • Macrophages phagocytose degraded myelin and axons

  24. Regeneration • Complete • Partial • Simple misdirection • Clinical expression: synkinesis or associated movement • Complex misdirection • Clinical expression: mass movement

  25. Differential Diagnosis • Extracranial • Intratemporal • Intracranial

  26. Extracranial 1.Traumatic • Facial lacerations • Blunt forces • Penetrating wounds • Mandible fractures • Iatrogenic injuries • Newborn paralysis

  27. Extracranial 2.Neoplasm • Parotid tumors • Tumors of the external and middle ear • Facial nerve neurinomas • Metastatic lesions 3.Congenital absence of facial musculature

  28. Intratemporal 1.Traumatic • Fractures of petrous pyramid • Penetrating injuries • Iatrogenic injuries 2. Neoplastic • Cholesteatoma • Facial neurinomas • Hemangiomas • Meningiomas • Acoustic neurinomas

  29. Intratemporal 3.Infectious • Herpes zoster oticus • Acute otitis media • Chronic otitis media • Malignant otitis externa 4.Idiopathic • Bell's palsy • Melkersson-Rosenthal syndrome 5. Congenital: osteopetroses

  30. Intracranial 1. Iatrogenic injury 2. Neoplastic 3. Congenital • Mobius syndrome • Absence of motor units

  31. History • Onset • Previous symptoms • Complete or incomplete • Unilateral or bilateral • Pain • Underlying disease (vestibulocochlear) • Associate symptoms • Alteration in taste or lacrimation

  32. History • Family history • Trauma • Hx of viral infection • Vaccination • DM • HTN • Pregnancy

  33. Physical examination • ENT exam • Nervous system • Location • Severity

  34. Evaluation of Facial paralysis • Clinical feature • Central VS Peripheral facial paralysis • Complete head and neck examination • Cranial nerve evaluation • Electrodiagnostic testing • Topographic diagnosis

  35. Central facial paralysis • Upper motor neurone lesion • Movements of the frontal and upper orbicularis oculi tend to be spared • Because of uncrossed contributions from ipsilateral supranuclear areas • Involvement of tongue • Involvement of lacrimation and salivation

  36. Peripheral paralysis • Lower motor neurone lesion • At rest : • less prominent wrinkles on forehead of affected side, eyebrow drop, flattened nasolabial fold, corner of mouth turned down • Unable to : • wrinkle forehead, raise eyebrow, wrinkle nasolabial fold, purse lips, show teeth, or completely close eye

  37. House-Brackmann grading system • Grade I- Normal • Grade II- Mild dysfunction, slight weakness on close inspection, normal symmetry at rest • Grade III- Moderate dysfunction, obvious but not disfiguring difference between sides, eye can be completely closed with effort • Grade IV- Moderately severe, normal tone at rest, obvious weakness or asymmetry with movement, incomplete closure of eye • Grade V- Severe dysfunction, only barely perceptible motion, asymmetry at rest • Grade VI- No movement

  38. Topographic Diagnosis • To determine the anatomical level of a peripheral lesion • Lacrimation  Geniculate ganglion • Stapedius reflex motor nerve of stapedius muscle • Taste  chorda tympani

  39. Schirmer'sTest • Geniculate ganglion & petrosal nerve function test • Schirmer’s test +ve when • Affected side shows less than half the amount of lacrimation seen on the normal side • Sum of the lengths of wetted filter paper for both eyes less than 25 mm • Lesion at or proximal to the geniculate ganglion

  40. Stapedius reflex • Nerve to stapedius muscle test • Impedance audiometry can record the presence or absence of stapedius muscle contraction to sound stimuli 70 to 100 dB above hearing threshold • An absence reflex or a reflex less than half the amplitude is due to a lesion proximal to stapedius nerve

  41. Taste (Electrogustometry) • Chorda tympani nervetest • Solution of salt, sugar, citrate, quinine or Electrical stimulation • Compares amount of current require for a response each side of tongue • Normal : difference < 20 uAmp(thresholds differening by more than 25%= abnormal) • Total lack of Chorda tympani : No response at 300 uAmp • Disadvantage : False +ve in acute phase of Bell’s palsy

  42. Minimal stimulation test • ใช้กระแสไฟฟ้าเปลี่ยนไปเรื่อย ๆ จนได้ ค่าที่น้อยที่สุด ที่สามารถทำให้เห็นกล้ามเนื้อใบหน้ากระตุก • การตรวจวิธีนี้อาศัยหลักเกณฑ์ • neurapraxia ใยประสาทที่อยู่ใต้ต่อรอยโรคสามารถนำกระแสไฟฟ้าได้ดี • axonotmesis ใยประสาทที่อยู่ใต้ต่อรอยโรคยังคงสามารถถูกกระตุ้นด้วยไฟฟ้าได้แต่ต้องใช้ปริมาณกระแสเพิ่มขึ้น • neurotmesis ใยประสาทไม่สามารถนำกระแสไฟฟ้าได้

  43. Minimal stimulation test • ขั้นแรกใช้กระแสไฟฟ้าจำนวนน้อยกระตุ้น • แล้วค่อย ๆ เพิ่มกระแสขึ้นจนได้ค่าน้อยที่สุดที่สามารถทำให้กล้ามเนื้อกระตุกใบหน้ากระตุกได้ • ทำทีละข้างของใบหน้า • เปรียบเทียบค่าที่ได้ของข้างที่มีรอยโรคกับข้างปกติ • ถ้าค่าต่างกันมากกว่า 3.5 mA Wallerian degeneration

More Related