LOWER MOTOR NEURON

(LMN)
FACIAL PALSY

Department of ENT
 FACIAL NERVE
• Is the 7th cranial nerve
• Nerve of 2nd Branchial arch
• mixed nerve
• Functions :
Motor
Sensory
Secretomotor
Taste sensation
PONS
SUPRA NUCLEAR
TRACT
INTERNAL ACOUSTIC MEATUS
TYMPANO MASTOID SEGMENT
 ETILOGY OF LMN
• Birth
• Trauma
• Infection
• Metabolic
• Neoplastic
• Toxic
• Iatrogenic
• Idiopathic
SUNDERLAND CLASSIFICATION
degree of injury

HOUSE BRACKMANN CLASSIFICATION

recovery
 Approach to pt
with LMN Facial Palsy

History :
• Onset :
• Duration :
• Progression :
• Recurrence :
• h/o Trauma :
• Family History
• H/o Medication
• h/o Pregnancy
• h/o Systemic illness/malignancy
• h/0 hearing loss
• h/o Tinnitus / vertigo
• h/o pain / ear discharge
 Physical examination
– E.N.T.
– Ear
– Nose
– Throat
– Complete neurological examination
– Facial Nerve examinationm
– Mass - Head Neck
– Weber’s,and Rinne’s tests
– Ocular Exam
DIFFERENCE :-

SUPRANUCLEAR INFRANUCLEAR
– Forehead intact Bilaterly – Total facial-palsy
Unilateral
– Emotion intact
– Emotion impaired
– Deficit of tongue
– No Deficit
fingers,hand
– Hemiplegia
– No Hemiplegia
• Epsilateral
– Ataxia – No ataxia
– Reflexes Intact – No Reflexes
– Spastic – Flaccid
 SUPRANUCLEAR INFRANUCLEAR

• No muscle atrophy • Muscle atrophy +

• No muscle- • Muscle- fasciculation+
fasciculation
• Electrical test • Electrical test
– MST responses equal- – MST responses equal-
bilaterally – Decrease or absent
– EEMG responses
– EEMG responses
normal
– Decrease or absent
 INVESTIGATIONS
• TOPO-DIAGNOSTICS TEST

– Audiometary (pure tone and speech)

– Vestibular Function test
– Schirmer’s test
– Stapes reflex
– Taste test (Elecrogustometry)
– Submandibular Salivary Flow Test
 ELECRO-DIAGNOSTIC
TEST
• Maximum stimulation test-(MST)
– Bilateral equal response up to 10 days -
92% chances of complete recovery
– If response lost within 10 days -
100% chances of incomplete recovery

• Evoked Electromyography-(EEMG)
Electromyography-(EMG)

– Test of nerve degeneration

– which occur 10 to 20 days after injury,
– appearance of fibrillation is diagnostic
Nerve Excitability Test
– Most commonly used
– Determines threshold level to elicit the facial
twitch
– Diff. Of > 3.5 m amp between 2 sides
- poor prognosis
 RADIOLOGICAL
INVESTIGATION
• X-ray Mastoids
• C.T.Scan Head(Brain stem,
C.P.angle,Temporal bone,skull base)
• High resolution C.T. to delineate fallopian
canal
• MRI with gadolinium enhancement-
labrithine & geniculate ganglion
• X-ray Chest
 LABORATORY TEST
• TLC,DLC,ESR
• Urine exam
• Serum Ca++,Urinary Ca++
• Serum globulin
• Thyroid function test
• Glucose tolerance test
• Bone Marrow Exam
DIFFERENTIAL DIAGNOSIS
LEVEL PROBABLE SIGNS
DIAGNOSIS

Cere- Vestibular Impaired hearing,ataxia,

bellopont schwannoma abnormality of tear & taste,
ine angle facial motor deficit,
stapes reflex decay,
C.T.Scan-no enhancement
with Contrast,
MRI-hyper intense mass

Meningioma Same
C.T. Scan enhancement with
Contrast.
cholesteatoma 7th,8th nerve deficit,
.or facial X-ray temporal Bone-
neuroma erosion or lytic lesion,

Glomus Deficit of 7th 8th 9th 10th

jugulare 11th &12th cranial nerve,
tumour Pulsatile tinnitus
Purple – red pulsating
mass bulging through
T.M.
Internal auditory Temporal bone Ecchymosis around pinna
meatus and fracture and mastoid,haemo-
tympanum SNHL, Vertigo,
Labrinthine Nystagmus, Sudden
segment Comlplete facial Paralysis
CSF Leak

Schwannoma Dry Eye salivation/ taste

Geniculate Meningioma CT Scan - Erosion of
Ganglion Cholestatoma Geniculate ganglion area

Herpes Zoster Pain in the ear, vesicles on

Cephalicus pinna, Face, Neck.
( ram say hunt SNHL/Vertigo
syndrome)
Acute onset, Numbness,
Bell’s Palsy pain in ear,face,neck,toung
 Unilatral facial palsy
taste / salivation/ lacrimation
loss of stapedeal reflex(same
side)

Tympano Herpes zoster

Mastoid cephalicus same as above
symmetrical tearing
Segment
Bells palsy
same as above
symmetrical tearing
ASOM
h/o URI red bulging TM,
conductive hearing loss
CSOM
usually ass. with h/o recurrent ear inf.
cholestatoma foul discharge +,
TM perforation +, hearing loss+
 Pulsatile tinnitus
glomus tympanicus Purple – red pulsating mass
noted through T.M.

Incomplete F.N paresis

Extra Penetrating injury of face
cranial Parotid surgery
Malignancy of parotid,
Tonsil or oro/nasopharynx
Benign lesion of Parotid
hearing balance, tearing,
stapedial reflex,taste,
salivaryflow
spared

Sarcoidosis Uveitis, salivarygland

Lymphoma enlargement, fever
 Treatment of Facial Paralysis
• Bell’s palsy
Medical T/t
Physical therapy
Pharmacological
Psychological
Eye care
Surgical T/t
Degeneration is > 90% normal
No evidence of neuropraxia
Age < 60 yrs.
Paralysis of < 21 days

Surgical approach-Decompression
Middle Cranial fossa
Trans-mastiod sublabrynthine
 Treatment of Traumatic Facial
Paralysis
ACCIDENTAL :
• Conservative T/t :
Onset-delayed or incomplete palsy
• Surgical exploration:
Onset-sudden or complete palsy
No response to electrical stimulation by 5th
day
SURGICAL (EAR SURGERY)_
If electrical response is lost by 5th post op day-
Re-exploration required
PAROTID SURGERY
• If Facial Twitching + - No need to worry
• If no response to direct stimulation, inspect
the nerve carefully
REPAIR OF SEVERED FACIAL NERVE
– Approximation-Gap- few mm
– Grafting- -Gap-more
– Greater auricular nerve
– sural nerve
FACIAL REANIMATION
– within 6month of onset of paralysis
– XII-VII cranial nerve graft
SEQUEALE & COMPLICATIONS

• Incomplete recovery
• Exposure keratitis
• Synkinesis(mass movt.)
• Tics and spasms
• Contractures
• Crocodile Tears( Gustatory lacrimation)
• Frieys syndrome(Gustatory sweating)
• Psychological and social problem