facial palsy
DESCRIPTION
Facial Palsy..causes..signs..treatmentTRANSCRIPT
GOOD MORNING
FACIAL PALSY
COMPILED BY: Dr.Nuzhat Noor Ayesha PG student (OMFS) KCDS- B’lore
• "The human face is the organic seat of beauty. It is the register of value in development, a record of Experience, whose legitimate office is to perfect the life, a legible language to those who will study it, of the majestic mistress, the soul."
• Farnham, Eliza
QUOTE
CONTENTS
IntroductionNerve anatomy & injuriesFacial nerve anatomyFacial paralysisEtiologyBell’s PalsySurgical treatmentReferences
INTRODUCTION• Facial function plays an integral part in our
everyday lives– Smile; nonverbal communication, etc.
• Facial paralysis is devastating on many levels– Functional– Cosmetic
• Fortunately, a plethora of techniques are available to treat the paralyzed face.
NERVE FIBER COMPONENTS
• Endoneurium– Surrounds each axon– Adherent to Schwann cell
layer– Vital for regeneration
• Perineurium– Encases endoneural tubules– Tensile strength– Barrier to infection
• Epineurium (nerve sheath)– Outermost layer– Houses vasa nervosum for
nutrition
NERVE INJURY
• Two acceptable classification schemes used to describe the histologic changes that occur following nerve injury.
SEDDON CLASSIFICATION (1943)
• Neurapraxia-a conduction block from transient anoxia owing to acute epineurial/endoneurial vascular interruption resulting from mild nerve manipulation with rapid and complete recovery of sensation.
• Axonotmesis- This damage extends through and includes the endoneurium with no significant axonal disorganization. Recovery is slow and may take weeks to months, and it may not be complete.
• Neurotmesis- injuries result from complete or near complete transection of the nerve with epineurial discontinuity and likely neuroma formation. Spontaneous neurosensory recovery is unlikely.
SUNDERLAND CLASSIFICATION (1951)
NEURAL HEALING
FACIAL NERVE
7th Cranial nerveNerve of the 2nd branchial
archHas two roots. A large
motor and a smaller mixed sensory and parasympathetic (nervus intermedius)
FACIAL NERVE
FUNCTIONAL COMPONENTS
• Brancial motor(special visceral efferent)-Supplies; Stapedius , Stylohyoid, posterior belly of digastric muscle and the muscles of facial expression.
• Visceral motor(general visceral efferent)
Parasympathetic innervations of the lacrimal, submandibular, and sublingual glands, as well as mucous membranes of nasopharynx, hard and soft palate.
•Special sensory(special afferent)-Taste sensation from the anterior 2/3 of tongue; hard and soft palates.
•General sensory(general somatic afferent)-General sensation from the skin of the concha of the auricle and from a small area behind the ear.
FUNCTION
The facial nerve is responsible for:
I. Contraction of the muscles of the face
II. Production of tears from a gland (Lacrimal gland)
III. Conveying the sense of taste from the front part of the tongue (via the Chorda tympani nerve)
IV. The sense of touch at auricular conchae
LEVEL OF NERVE INJURY AND SYMPTOMS
FACIAL PARALYSIS
Commonly Unilateral
Nuclear- from destruction of the nucleus
Central or cerebral or Supranuclear
Peripheral- from a lesion of the nerve
NUCLEAR LESIONS
Supranuclear lesions- usually a part of hemiplegia, only the lower part of the face is paralysed. The upper part (frontalis and part of orbicularis oculi)escapes due to bilateral representation in the cerebral cortex.
Infranuclear lesions- entire face is paralysed, as seen in bell’s palsy
ETIOLOGIC CLASSIFICATON OF FACIAL PALSY
Various classification have been suggested in this respect.
Based on:Course of the nerve
Various etiologic causes
Degree of dysfunction observed
Vascular abnormalitiesCNS degenerative diseasesTumours of the intracranial cavityTrauma to the brainCongenital abnormalities and agenesis
INTRACRANIAL (CENTRAL) CAUSES
Bacterial and Viral infectionCholesteatomaTrauma- blunt temporal bone trauma,
longitudinal and horizontal fractures of the temporal bone and gunshot wounds.
Tumours invading the middle ear, mastoid and facial nerve
Iatrogenic causes
INTRATEMPORAL CAUSES
Malignant tumours of the parotid glandTraumaIatrogenic causesPrimary tumours of the facial nerveMalignant tumours of the ascending ramus of the
mandible, pterygoid region and skin.
EXTRACRANIAL CAUSES
RAINER SCHMELZEISEN CLASSIFICATION
CONGENITAL Moebius Syndrome Myotonic dystrophy Melkersson Rosenthal syndrome Congenital Cholesteatoma Birth injuries Osteopetrosis
NEUROLOGIC Myasthenia Gravis Multiple Sclerosis Guillain Barre syndrome
NEOPLASTIC Facial nerve tumours Glomus tumours Meningiomas, acoustic
neuroma Parotid tumours Temporal bone/external
auditory meatus tumours
INFECTIONS Otitis media, mastoiditis Bacterial causes Viral causes
HOUSE-BRACKMAN(1985) CLASSIFICATION
• Grade I-normal function without weakness.• Grade II-mild dysfunction with sligth facial asymmetry with
a minor degree of synkinesis.• Grade III-moderate dysfunctions-obvious, but not
disfiguring, asymmetry with contracture and/or hemifacial spasm, but residual forehead motion and incomplete eye closure.
• Grade IV-moderately severe dysfunction- obvious, disfiguring asymmetry with lack of forehead motion and incomplete eye closure.
• Grade V-severe dysfunction-asymmetry at rest and only slight facial movement.
• Grade VI-total paralysis-complete absence of tone or motion.
Facial Paralysis
CongenitalMÖbius syndromeMyotonic dystrophy
Infectious/IdiopathicMelkerson-Rosenthal syndromeRamsay-HuntOtitis media/mastoiditis/meningitisLyme DiseaseNecrotizing Otitis externaHIV, TB, EBV, syphillisTetanus
Toxins/TraumaHead traumaTemporal bone traumaBirth trauma
TumorParotidAcoustic neuromaGliomaMeningiomaFacial neuroma
EndocrineDMPregnancyHyperthyroidism
NeurologicGuillian-BarreMyasthena GravisStrokeMultiple sclerosis
SystemicSarcoidosisAmyloidosisHyperostosis
BELL’S PALSY
• It is defined as an idiopathic paresis or paralysis of the facial nerve of sudden onset.
• The name was ascribed to SIR CHARLES BELL, who in 1821 demonstrated the separation of motor and sensory innervation of face.
• INCIDENCE-15-40 cases per 1 lakh cases
• SEX PREDILECTION- women more affected than men.3.3 more times common in pregnancy and in the third trimester.
• AGE- can occur at any age, common in middle aged people.
• SIDE INVOLVMENT- can be equally seen, usually unilateral.
CLINICAL FEATURES
• There is sudden onset, usually pt gives h/o occurrence after awakening early morning.
• Unilateral involvement of entire side of the face.
• Abrupt loss of muscular on one side of face.
• Inability to smile, close the eye or raise the eyebrow on affected side.
• Whistling is not possible.
• In an attempt to close eyelid, the eyeball rolls upward.
• Inability to wrinkle forehead or elevate upper or lower lip.
• Obliteration of nasolabial fold.
Face appears distorted and mask like appearance to the facial features.
Speech becomes slurred.
Occasionally there is loss or alternative of taste.
Course and prognosis
Partial paralysis always resolves completely within a few weeks.
Recovery from complete paralysis takes longer (months) and is complete in only about 60-70% of cases.
Approximately 15% of patients are left with troublesome
residual palsy and or synkinesis.
COMPLICATIONS OF FACIAL PARALYSIS
Facial paralysis severely hinders:• Normal facial expressions• Mastication• Speech production• Eye protection.
Psychological Trauma• The most significant complication is the social
isolation these patients often succumb to.
COMPLICATIONS
The most serious complication is corneal damage. One of the greatest problems with Bell's palsy is the involvement of the eye if the lid fissure remains open. In this case, eye care focuses on protecting the cornea from dehydration, drying, or abrasions due to insufficient lid closure or tearing
ASSESSMENT AND PLANNING
Cause of facial paralysisFunctional deficit/extent of paralysisTime course/duration of paralysis
Likelihood of recovery
Other cranial nerve deficitsPatient’s life expectancyPatient’s needs/expectations
EVALUATIONS OF NERVE FUNCTION
• HISTORY is of vital importance to establish the onset characteristics,duration and degree of recovery.
• Previous trauma, surgery or infection may help in arriving at a diagnosis
• Examination of the face at rest and movement.• Radiolologic evaluations• Nerve excitability tests.
• TEAR TEST: (Schirmer’s test)• Semiquantitative method for comparing lacrimal
secretion on normal & affected side.• 0.5×5cm strip of filter paper.• If moistened length in affected side <25% of
normal: significant hyposecretion is present.
TASTECHORDA TYMPANI: • Subjective loss of sensation: unreliable symptom.• Swab sides of tongue by a cotton applicator dipped in lemon juice.• Threshold measured with electrogustometer (measured electric
current). N:30gk microamp• Patient percieves this as sour or metallic.
SALIVARY FLOW• Cannulate wharton duct on each side with no.50 polyethylene tube• Stimulate saliva with lemon juice• Output of saliva measured in each tube• 25% reduction is significant• Indicates interruption of chorda tympani or facial nerve to this branch.• LIMITATIONS- Unequal penetration of cannula, assymetry of glands.
ELECTRICAL TESTING OF FACIAL NERVE
MAXIMUM STIMULATION TEST• Pulsed electric current is delivered through a cutaneous
electrode• Short pulse will stimulate an intact nerve & elicit a
muscular twitch.• In paralysed facial nerve, this indicates that lesion is
neuropraxia & distal neurons have not undergone degeneration
• Hence differentiates between neuropraxia & axonotmesis: prognostic value.
NERVE EXCITABILITY TEST:• Current required for stimulation on normal side is compared with
paralysed side.• Disadv: even few intact fibres can elicit a response when rest in
undergoing degeneration.
Muscle twitch response is subjective
Uncomfortable procedure
Requires patient co-operation
ELECTRONEUROGRAPHY• Measures compound action potential in facial muscles in response to
facial nerve stimulation.• Similar to MST, except instead of visually ration the muscle
contraction, the muscle action potential is measured on EEG- more accurate.
• Best test to predict & follow facial nerve recovery.• Compare & represent it as percentage of normal side.
Treatment
• Oral antivirals - Acyclovir • Corticosteroids• Eye protection • Follow progression with serial exams• Physiotherapy
MEDICATION
• If the patient is seen within 2 to 3 weeks of onset of symptoms-tab. Prednisolone in doses of 1mg/kg/d for 10 to 14 days has been recommended with a gradual tapering.
• Vitamins B1, B6, B12 may be administered.• If pt is seen after 3-4 weeks, then steroid therapy
is of no use.
SURGICAL TREATMENT MODALITIES
• Nerve decompression - Internally or externally
• Nerve anastomosis
• Nerve grafting
A. Acute (< 3 wks)
1. Nerve exploration/decompression
2. Nerve repair
a. Primary anastomosis
b. Cable grafting
i. Great auricular nerve
ii. Sural nerve
B. Intermediate (3 wks- 2 yrs)
1. Nerve transfer
a. Hypoglossal-facial
b. Spinal accessory-facial
c. Masseteric-facial
2. Cross face nerve grafting using sural nerve
C. Chronic (>2 yrs) 1. Muscle transfers a. Temporalis b. Masseter c. Digastrics 2. Free muscle flaps/ microneurovascular transfer a. Gracilis b. Latissimus dorsi c. Serratus anterior d. Pectoralis minor
D. Static procedures/ancillary procedures (can be performed at any time period listed above) 1. Gold weight/spring implants 2. Slings 3. Lid procedures
Ryan Ridley. Facial Reanimation .Grand Rounds Presentation, UTMB, Dept. of Otolaryngology
SURGICAL TREATMENT MODALITIES
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.
PRIMARY NERVE REPAIR
End-to-end anastomosis preferredNo tension
Extratemporal repair performed < 72 hrs of injury
Most common methodsGroup fascicular repairEpineural repair Group fascicular repair
Primary Nerve Repair Severed ends of nerve
exposedDevitalized tissue/debris
removed with fine scalpelSmall bites of epineurium
Epineural sheath approximated with 9-0 nonabsorbable sutureEpineural repair recommended
for injury proximal to pes anserinus and intratemporal
EPINEURAL REPAIR TECHNIQUE
INTERPOSITION GRAFTING
Cable graftsUsed when defect > 17mm; nerve cannot be
reapproximated without tensionMost common
Greater Auricular Nerve Sensory nerves from superficial cervical plexus Sural nerve
INTERPOSITION GRAFTING GREATER AURICULAR NERVE
Harvesting Located on lateral surface of
SCM at the midpoint of a line drawn between mastoid tip and mandibular angle
May extend postauricular incision or use separate neck incision
Advantages: Proximity to facial nerve Cross-sectional area Limited morbidity
Limitations: Reconstruction of long defects Ideal for defects < 6cm in length
SURAL NERVE• Anatomy
– Formed by union of medial sural cutaneous nerve and lateral sural cutaneous branch of peroneal nerve.
Advantages : Length : >12cm Accessibility Low morbidity associated with
sacrifice
Disadv: Variable caliber
Often too large Difficult to make graft approximation
Unsightly scar
NERVE TRANSPOSITION/ CROSSOVER
• 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.
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CROSSOVER TECHNIQUES
INDICATIONS: Irreversible facial nerve injury Intact facial musculature/distal facial nerve Intact proximal donor nerve Prior to distal muscle/facial nerve atrophy
Ideal if performed within a year of facial paralysis
Adv: Time interval until movement
4-6 months Avoid multiple sites of anastomosis Mimetic-like function achievable with practice
Disadv: Donor site morbidity Some degree of synkinesis
Hypoglossal-Facial Technique1. Parotidectomy incision extended
into cervical crease ~ 2-3 cm below inferior border of mandible
2. Facial nerve identified and dissected distal to pes anserinus
3. Identify hypoglossal nerve
a. SCM retracted posteriorly
b. Dissect superiorly until posterior belly of digastic is identified
c. Retract digastric superiorly and CN XII is found inferiorly.
d. Hypoglossal is within
2-3 c m of main trunk of the facial nerve
4. Hypoglossal nerve is dissected anteriorly and medially into the tongue.
1. Transect distal to ansa hypoglossis
5. Facial nerve transected at the stylomastoid foramen
6. Anastomose nerves using 9-0 epineural suture.
Hypoglossal Facial Nerve Transfer
Entire hypoglossal nerve transected
40% segment of nerve secured to
lower division.
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Hypoglossal nerve reflected superiorly
Hypoglossal Facial Nerve Transfer
Jump graft modificationReflection of the facial nerve out of the mastoid bone.
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CROSS-FACIAL NERVE GRAFTING
• Contralateral Facial nerve used to reinnervate paralyzed side using a nerve graft– Sural nerve often employed– ~25-30cm of graft needed
• Restitution of smile and eye blinking obtained.• Disadvantage
– 2nd surgical site– Violation of the normal facial nerve
CROSS-FACIAL NERVE GRAFTING
FOUR techniques Sural nerve graft routed from buccal
branch of normal VII to stump of paralyzed VII
Zygomaticus and buccal branch of normal VII used to reinnervate zygomatic and marginal mandibular portions respectively
4 separate grafts from temporal, zygomatic, buccal and marginal mandibular divisions of normal CN VII to corresponding divisions on paralyzed side.
Entire lower division of normal side grafted to main trunk on paralyzed side.
MUSCLE TRANSPOSITION (“DYNAMIC SLING”)
INDICATION:– Congenital facial paralysis – Facial nerve interruption of at least 3 years
• Loss of motor endplates
– Crossover techniques not possible due to donor nerve sacrifice
TEMPORALIS
Often used for reanimation of the oral commisure.
Middle 1/3 of muscle is best for transfer (Sherris, 2004)
Temporalis Transfer
1. Incision in preauricular crease extending to superior temporal line
2. Obtain wide exposure of temporalis muscle by dissecting above the SMAS
3. Incise down on periosteum to elevate muscle fibers
-Harvest middle 1/3
4. Large tunnel created over zygomatic arch
5. Orbicularis oris muscle exposed via vermilion border incision at oral commissure
6. Large tunnel over zygomatic arch used to connect oral commisure to zygomatic arch/superior incision.
7. Temporalis flap detached and elevated from its origin and tunneled to the oral commissure.
8. 3-0 prolene used to suture orbicularis to temporalis at oral commissure
9. Overcorrection of nasolabial fold and oral commissure
MASSETER
• Used when temporalis muscle is not opted.• May be preferred due to avoidance of large facial
incision• Disadvantage:
– Less available muscle compared to temporalis– Vector of pull on oral commisure is more horizontal
than superior/oblique like temporalis
Masseter Transfer
1. Expose muscle with gingival incision along mandibular sulcus
2. Dissection carried out in a plane between mucosa and muscle.
3. Muscle freed off of mandible medially and from the inferiolateral edge of mandible.
4. Vertical incision made in inferior portion of muscle
5. Anterior half of muscle is split into 2 divisions.
6. The 2 anterior slips of muscle are tunneled anteriorly to reach the oral commisure via external vermillion border incisions
7. Muscle slips are attached to lips and oral commisure in the deep dermal layer using suture
MICRONEUROVASCULAR TRANSFERFREE MUSCLE FLAPS
• They have potential of achieving individual segmental contractions– Reduction of synkinesis
• Muscle flaps used are:– Gracilis– Latissimus dorsi– Inferior rectus abdominus
MICRONEUROVASCULAR TRANSFERFREE MUSCLE FLAPS
Requires viable muscle and nerve innervation Traditionally done in 2 stages
1st: Cross-face nerve graft ~ 1 yr prior to muscle transfer 2nd: Muscle transfer performed after neural ingrowth of graft
GRACILIS 1. “Workhorse” for free muscle
transfer
2. Long, thin muscle in medial thigh
-Good neurovasular pedicle
1. Adductor artery and vein
2. Anterior obturator nerve
3. 2 stages involved:
1. Sural nerve employed for cross-face graft
2. Gracilis muscle transferred after 6-12 months
4. Vascular anastomosis to the facial artery and vein or to superficial temporal vessels.
5. Obturator nerve of gracilis connected to distal end of sural nerve graft.
Anterior Obturator nerveAdductor a. & v.
ADDRESSING PARALYTIC EYELIDS Complications of orbicularis oculi paresis
Delayed blinking Impairment of nasolacrimal systemDry eyeRisk of exposure keratitis, corneal ulceration and
blindness
Goal of treatment is to maintain cornea
Treatment OptionsTarsorrhaphyGold weight/spring implantsOpen / endoscopic brow lifts for significant brow ptosis
GOLD WEIGHT IMPLANTATION
1. Small incision made several millimeters above the upper eyelid margin.
2. Tarsal plate exposed with sharp dissection
3. Gold weight secured to tarsus using 8-0 nylon.
4. Wound closed in 2 layers
Horizontal mattress 5-0 nylonBegin 3mm medial to lateral canthus, 6mm from lid marginStitch travels through gray line to 5mm below lower lid marginBolster with 3mm, 4-french rubber catheter.Cosmetically unappealing, visual field affected.
TARSORRHAPHY
Surgical management of LAGOPHTHALMOS
• F. Stagno d’Alcontres, G. Cuccia*, F. Lupo, G. Delia, M. RomeoThe orbicularis oculi muscle flap: Its use for treatment of lagophthalmos. Journal of Plastic, Reconstructive & Aesthetic Surgery (2010) 63, 416e422
STATIC PROCEDURES
Indications: Debilitated individuals; poor prognosis Nerve or muscle not available for dynamic procedures Adjuct procedure with dynamic techniques to provide
immediate benefit
Advantages: Immediate restoration of facial symmetry at rest No oral commisure ptosis
Drooling, disarticulation, mastication difficulties
Relief of nasal obstruction caused by alar collapse
• 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.
STATIC SLINGS
Variety of materials used• PTFE (Gor-Tex)• Alloderm• Fascia lata
Gor-Tex and alloderm have advantage of no donor site morbidity but higher risk of infection.
STATIC FACIAL SLING TECHNIQUE
1. Preauricular, temporal or nasolabial fold incision may be used
2. Additional incisions made adjacent to oral commisure at vermillion border of upper and lower lip
3. Subcutaneous tunnel dissected to connect temporal to oral commisure incisions
4. Dissection may be carried out in midface adjacent to nasal ala, if needed (for alar collapse)
5. Implant strip is split distally to connect to the upper/lower lips
6. Implant secured to orbicularis oris/commisure using permanent suture
7. Implant is suspended and anchored superiorly to superficial layer of deep temporal fascia, or zygomatic arch periosteum, using permanent suture.
8. May also secure to malar eminence using small miniplate or bone anchoring screw
REFERENCES
• Cranial nerves-Functional Anatomy – Stanley Monkhouse• Anatomy for Surgeons: Hollinshead• Maxillofacial surgery: Peter Ward Booth Vol 1 & 2• Peterson’s Principles of Oral & Maxillofacial Surgery, 2nd edition. • Oral pathology- Regezi.• Textbook of oral surgery – Neelima Malik • Gray’s anatomy.• Text of Anatomy by Roylce.
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