Facial Paralysis Lecture Ready2
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- Words: 2,752
- Pages: 107
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
بسم الله الرحمن الرحيم
يؤتى الحكمة من يشاء يؤت الحكمة فقد أوتى اكثيرا
ومن خير
صدق الله العظيم (البقرة )269
الحكمة :القدرة على الفهم و التمييز )و الصابة فى القول والفعل (الطبرى
Facial nerve paralysis by M. Hisham Hamad Prof. Otolaryngology Tanta University
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Problem solving and MCQ Questions
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
•What is the lesion? •Side)Rt or Lt( •Site )U or lower(
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Problem solving
• This gentleman presented with right severe otalgia and drippling of saliva from the right side of the mouth with collection of food in the right cheek during meals. No other associated symptoms or sign were noted.
• What is the most probable diagnosis?
Prof. Hisham Hamad
• This gentleman is 50 ys old presented with one day history of “my face isn’t moving”
Problem solving
– Occurred overnight – No ear pain, previous viral illness – No hearing loss – No prior history, no family history – No other associated symptoms
• 4 weeks he started to feel some movement in his face.
Prof. Hisham Hamad
• Recurrent Facaial paralysis occurning few days after onset of acute otitis media denotes A.Bulging tympanic membrane B.mastoiditis C.Congenital anomaly of the ear D.Immunodefiency
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
• Bells balsy is commonly treated with: A.
antihistaminic and steroids
B.
antihistaminic and antiviral
C. antiviral And steroids D. antibiotic and steroids
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
• Progressive unilateral LMN Facaial paralysis over more than 3 monthes without identified aetiology is most probably due to A. Bell s balsy B. Brain tumor in motor area of temporal lobe C. Acoustic nerve neuroma D.Malignant otitis externa
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Anatomy origin
3 nuclei motor sup salivary T solitarius Mixed nerve Gen Motor Secretomotor Gen Sensory Sp sensory )taste( Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Anatomy origin
3 nuclei motor sup salivary T solitarius
Mixed nerve Gen Motor Secretomotor Gen Sensory Sp sensory (taste)
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Anatom y distributio n
Mixed nerve General Motor Secretomotor General Sensory Special sensory )taste( Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Anatom y
Mixed nerve
Motor muscles of facial expression Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Anatom y Mixed nerve Secretomotor lacrimal gl submandibular sublingual
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Anatom y Mixed nerve Secretomotor lacrimal gl submandibular sublingual
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Anatom y Mixed nerve Special sensory
tase ant 2/3 of tongue
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Anatom y Mixed nerve General sensory
concha & ext canal
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Motor UMN pyramidal bilateral to upper face
extra-pyramidal emothional movement
LMN
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Motor UMN pyramidal bilateral to upper face extra-pyramidal emothional movement
LMN
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Motor UMN
pyramidal voluntary movement
extra-pyramidal
emothional movement
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Motor UMN suranuclear pyramidal extra-pyramidal
LMN nuclear infranuclear
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
UMNL # LMNL Site of lesion Side of paralysis Emotional movement Upper face movement Type of lesion Sequallae of paralysis Bell s phenomenon Associates Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
UMNL # LMNL
Flaccid paralysis
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
UMNL # LMNL
Sequallae of paralysis
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
UMNL # LMNL
Bell s phenomenon
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Motor lesion level UMN supranuclear Δ extra Δ
LMN
nuclear CPA meatal lanyrinthine horizontal tympanic vertical mastoid SM foramen peripheral
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Motor LMN nuclear CPA meatal
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Motor LMN nuclear CPA meatal lanyrinthine
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Motor
LMN nuclear CPA meatal lanyrinthine
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Motor LMN nuclear CPA lanyrinthine horizontal tympanic
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Motor LMN nuclear CPA meatal lanyrinthine horizontal tympanic vertical mastoid
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Motor LMN nuclear CPA meatal lanyrinthine horizontal tympanic vertical mastoid SM foramen
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Motor LMN nuclear CPA meatal lanyrinthine horizontal tympanic vertical mastoid SM foramen peripheral
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Motor LMN nuclear CPA meatal lanyrinthine horizontal tympanic vertical mastoid SM foramen peripheral
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Relations & LMN branches nuclear )6 N( th
N(
CPA )cerebellum & N intermedius & 8TH meatal )8th N(
LMN branches level greater petrosal N to stapedius chorda tympani peripheral
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Disorders of the facial nerve
Motor dysfunction hypokinetic hyperkinetic blepherospasm & facial tics hemifacial spasm facial myokymia focal siezure synkinesia tic doulaureux )trigeminal nueralgia( Autonomic crocodile tears sphenopalatine neuralgia Sensory herpes zoster otalgia Bell s palsy taste disturbance
Pathophysiology
Idiopathic
mostly viral
Traumatic Inflammatory neoplastic Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Pathophysiology
Neuropraxia Axontemesis neurotmesis Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Sunderland classification of peripheral nerve injury Neurapraxia
Axonotmesis
Neurotmesis
Pathophysiology Wallerian degeneration Absent in neuripraxia
Occurs in
axontemesis neurontesis
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Pathophysiology Wallerian degeneration Absent in neuripraxia
Occurs in
axontemesis neurontesis
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Pathophysiology
Neuropraxia Axontemesis neurotmesis Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Pathophysiology Regeneration Intact sheath good recovery
Disrupted sheath
failure )residual paralysis + atrophy( misdirection to other muscles)synkinesia( taste to lacrimal gland )crocodile tears( parotid fibres to sweat glands )frey syn to other axons)short circuiting(
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
TESTS OF THE FACIAL NERVE
Site of lesion)topognostic( Electrodiagosis )prognostic( Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
TESTS OF THE FACIAL NERVE Site of lesion)topognostic( 1-G petrosal N schirmer test 2-N to stapedius stapedial reflex 3-chorda tympani a(taste gustometry b(salivary flow 5-peripheral brabches segmental facial movement Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
TESTS OF THE FACIAL NERVE Site of lesion)topognostic( 1-G petrosal N schirmer test 2-N to stapedius stapedial reflex 3-chorda tympani a(taste gustometry b(salivary flow 5-peripheral brabches segmental facial movement Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Topognostic Test • Lacrimal – Schirmer’s Test
• Stapedial reflex • Taste • Salivary flow
TESTS OF THE FACIAL NERVE Electrodiagosis )prognostic( 1-nerve excitability test
3.5 mA difference is significant
2-strength duration curve normal, partial or denervation curves
3--maximal N stimulation test 4 electromyography voluntary,fibrillation denervation or polyphasic reinnervation potentials
5-electroneurography the most informative
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
TESTS OF THE FACIAL NERVE
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
TESTS OF THE FACIAL NERVE Electroneurography the most informative quantitative
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Diagnosis Paralysed or not? Where is the lesion? How much is the degeneration? What is the lesion?
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
1-Paralysed or not? Clinical picture
At rest Voluntary movement Emotional movement Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Clinical picture At rest
)Due to unoppoesd pull of active muscles(
Loss of Forhead whrinkes Nasolabial fold Dead wide Eye Mouth Dropped angle Shortened on active
side
drippling from angle
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Clinical picture
Voluntary movement During eating During talking ask him to Whrinkle forehead Raise eyebrow Close the eye Show your teeth Blow your cheek To whistle
Emotional movement Prof. Hisham Hamad Copyright, 1996 © Dale Carnegie & Associates, Inc.
Clinical picture
During Close the Blow the Show th voluntary eyes teeth cheek movement
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
2-Where is the lesion UMNL or LMNL LMNL what level nuclear CPA meatal at geniculate( suprapyramidal infrapyramidal at stylomastoid F extratemporal
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
UMNL # LMNL Site of lesion Side of paralysis Emotional movement Upper face movement Type of lesion Sequllae of paralysis Bell s phenomenon Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
2-Where is the lesion UMNL or LMNL LMNL what level nuclear CPA meatal at geniculate( suprapyramidal infrapyramidal at stylomastoid F extratemporal
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
2-Where is the lesion UMNL or LMNL LMNL what level nuclear CPA meatal at geniculate( suprapyramidal infrapyramidal at stylomastoid F extratemporal
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
2-Where is the lesion UMNL or LMNL LMNL what level nuclear CPA meatal at geniculate( suprapyramidal infrapyramidal at stylomastoid F extratemporal
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
2-Where is the lesion? topognostic tests 1-G petrosal N schirmer test 2-N to stapedius stapedial reflex 3-chorda tympani a(taste gustometry b(salivary flow 5-peripheral brabches segmental facial movement
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
2-Where is the lesion
UMNL or LMNL LMNL
AR(
nuclear )6th N+ hemiplegia + all Normal( CPA )cerebellum+ 8TH N + N intermedius( meatal )No celebellar( at geniculate)No 8TH N( tympanic )Normal tearing( mastoid )Normal tearing & N at stylomastoid F )all Normal( extratemporal )segmental(
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
3-How much
degeneration Degree does not matter Incomplete paralysis always recovers well Complete paralysis recovers well if neuropraxic if degeneration is less than 90% Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
3-How much
degeneration Elecrodiagnostic tests Elecroneurography test
IS THE MOST VALUEBLE QUANTITATIVE 90 % or less degeneration denotes poor recovery
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
4-What is the lesion ? Idiopathic Inflammatory
malig OE AOM, A mastoiditis ch OM, H zoster
Traumatic F base, forceps cut wound Iatrogenic brain, ear, parotid Neoplastic primary 2ndary Toxic metabolic
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
4-What is the lesion ? Idiopathic Inflammatory
malig OE AOM, A mastoiditis ch OM, H zoster
Traumatic F base, forceps cut wound Iatrogenic brain, ear, parotid Neoplastic primary 2ndary Toxic metabolic
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
4-What is the lesion ? Idiopathic Inflammatory
malig OE AOM, A mastoiditis ch OM, H zoster
Traumatic F base, forceps cut wound Iatrogenic brain, ear, parotid Neoplastic primary 2ndary Toxic metabolic
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Complications Psychological Drooling Eye complications exposure keratitis infection )up to panophthamitis( Persistent paralysis Tics & spasm Atrophy & contracture Crocodile tears Frey syndrome
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Treatment:
Of the cause
Avoid complication
Avoid complication eye muscle atrophy residual paralysis Treat established complications residual paralysis crocodile tears $ gustatory sweating
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Treatment:
Avoid complication
Of the cause antibiotic in malignant OE Acyclovir if viral )H zoster & Bell s( myringotomy if early in AOM mastoidectomy if late in AMO mastoidectomy if in chronic MO Avoid complication Treat established complications
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Treatment:
Of the cause
Avoid complication
Avoid complication eye
glasses
artificial tears & ointment & dark tarsorraphy or
gold weight
implant muscle atrophy adhesive tape phsiotherapy )passive $ active( residual paralysis medically steroid surgical if more than 90% deg decompression reanastonosis grafting
Treatment:
Avoid complication
Treatment: Surgery Guidelines If partial If complete tests degeneration
No surgery do elecrodiagnosis till till
recovery 90%
if more than 90% degeneration do decompression )partial injury( reanastomosis )complete injury( nerve grafting )tissue loss(
Treatment: eye Avoid eye complication artificial tears ointment tarsorraphy gold weight implant
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Prof. Hisham Hamad
Gold weight implanta tion
Treatment: Avoid complication Of the cause Avoid complication Treat established complications
residual paralysis reanimation )if irreversible( dynamic graft facio-facial )cross face( hypoglossal to facial free micro-neurovascular static )sling( facia lata temporalis muscle masseter muscle crocodile tears $ gustatory
Dynamic reanimatiom graft
facio-facial )cross face(
hypoglossal to facial
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Dynamic reanimatiom free micro-neuro-vascular
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
static reanimatiom
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Bell s palsy Definition:: idiopathic+ unilateral+ LMNL of the facial nerve Aetiolgy: Idiopathic Ischeamia primary )cold( 2ary)viral or autoimmune( Polymerase chain reaction )PCR( have demonstrated herpetic infection in most of the ceses. A better term is viral or herpetic facial paralysis.
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Diagnosis:
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Treatment:
prognosis
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Treatment:
No treatment for partial paralysis Complete paralysis give : Cortisone Acyclovir VD ?? + neurotropic vitamins ?? Surgical decompression if degeneration exceeds 90% physiotherapy afterv 2 weeks dark glasses + eye ointment +adhesive tapes Prof. Hisham Hamad Copyright, 1996 © Dale Carnegie & Associates, Inc.
Problem solving and MCQ Questions
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
•What is the lesion? •Side)Rt or Lt( •Site )U or lower(
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
•What is the lesion? •Side)Rt or Lt( •Site )U or lower(
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
•What is the lesion? •Side)Rt or Lt( •Site )U or lower(
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
•What is the lesion? •Side)Rt or Lt( •Site )U or lower(
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Problem solving
• This gentleman presented with right severe otalgia and drippling of saliva from the right side of the mouth with collection of food in the right cheek during meals. No other associated symptoms or sign were noted.
• What is the most probable diagnosis?
Prof. Hisham Hamad
Problem solving
• This gentleman is 50 ys old presented with one day history of “my face isn’t moving” – Occurred overnight – No ear pain, previous viral illness – No hearing loss – No prior history, no family history – No other associated symptoms
• 4 weeks he started to feel some movement in his face.
• What is the most probable diagnosis?
Prof. Hisham Hamad
• Recurrent Facaial paralysis occurning few days after onset of acute otitis media denotes A.Bulging tympanic membrane B.Mastoiditis C.Congenital anomaly of the ear D.Immunodefiency
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
•Bells balsy is commonly treated with: A( antihistaminic and steroids B( antihistaminic and antiviral C( antiviral And steroids D( antibiotic and steroids
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
•Progressive unilateral LMN Facaial paralysis over more than 3 monthes without identified aetiology is most probably due to •A( Bell s balsy
•B( Brain tumor in motor area of temporal tempora lobe •C Acoustic nerve neuroma •D( Malignant otitis externa
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
1. Most prescribe steroids. The benefit is controversial. Conversely, 60mg of Prednisone for 7-10 days has only minor risks 2-The prognosis is so poor for Herpes Zoster Oticus cases that specialty consultation is required for patient satisfaction )that all possible was done( and for the PCP's medical legal protection. 3-Possible Lyme disease in endemic areas
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
بسم الله الرحمن الرحيم
يؤتى الحكمة من يشاء يؤت الحكمة فقد أوتى اكثيرا
ومن خير
صدق الله العظيم (البقرة )269
الحكمة :القدرة على الفهم و التمييز )و الصابة فى القول والفعل (الطبرى
Facial nerve paralysis by M. Hisham Hamad Prof. Otolaryngology Tanta University
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Problem solving and MCQ Questions
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
•What is the lesion? •Side)Rt or Lt( •Site )U or lower(
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Problem solving
• This gentleman presented with right severe otalgia and drippling of saliva from the right side of the mouth with collection of food in the right cheek during meals. No other associated symptoms or sign were noted.
• What is the most probable diagnosis?
Prof. Hisham Hamad
• This gentleman is 50 ys old presented with one day history of “my face isn’t moving”
Problem solving
– Occurred overnight – No ear pain, previous viral illness – No hearing loss – No prior history, no family history – No other associated symptoms
• 4 weeks he started to feel some movement in his face.
Prof. Hisham Hamad
• Recurrent Facaial paralysis occurning few days after onset of acute otitis media denotes A.Bulging tympanic membrane B.mastoiditis C.Congenital anomaly of the ear D.Immunodefiency
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
• Bells balsy is commonly treated with: A.
antihistaminic and steroids
B.
antihistaminic and antiviral
C. antiviral And steroids D. antibiotic and steroids
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
• Progressive unilateral LMN Facaial paralysis over more than 3 monthes without identified aetiology is most probably due to A. Bell s balsy B. Brain tumor in motor area of temporal lobe C. Acoustic nerve neuroma D.Malignant otitis externa
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Anatomy origin
3 nuclei motor sup salivary T solitarius Mixed nerve Gen Motor Secretomotor Gen Sensory Sp sensory )taste( Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Anatomy origin
3 nuclei motor sup salivary T solitarius
Mixed nerve Gen Motor Secretomotor Gen Sensory Sp sensory (taste)
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Anatom y distributio n
Mixed nerve General Motor Secretomotor General Sensory Special sensory )taste( Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Anatom y
Mixed nerve
Motor muscles of facial expression Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Anatom y Mixed nerve Secretomotor lacrimal gl submandibular sublingual
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Anatom y Mixed nerve Secretomotor lacrimal gl submandibular sublingual
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Anatom y Mixed nerve Special sensory
tase ant 2/3 of tongue
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Anatom y Mixed nerve General sensory
concha & ext canal
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Motor UMN pyramidal bilateral to upper face
extra-pyramidal emothional movement
LMN
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Motor UMN pyramidal bilateral to upper face extra-pyramidal emothional movement
LMN
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Motor UMN
pyramidal voluntary movement
extra-pyramidal
emothional movement
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Motor UMN suranuclear pyramidal extra-pyramidal
LMN nuclear infranuclear
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
UMNL # LMNL Site of lesion Side of paralysis Emotional movement Upper face movement Type of lesion Sequallae of paralysis Bell s phenomenon Associates Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
UMNL # LMNL
Flaccid paralysis
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
UMNL # LMNL
Sequallae of paralysis
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
UMNL # LMNL
Bell s phenomenon
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Motor lesion level UMN supranuclear Δ extra Δ
LMN
nuclear CPA meatal lanyrinthine horizontal tympanic vertical mastoid SM foramen peripheral
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Motor LMN nuclear CPA meatal
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Motor LMN nuclear CPA meatal lanyrinthine
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Motor
LMN nuclear CPA meatal lanyrinthine
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Motor LMN nuclear CPA lanyrinthine horizontal tympanic
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Motor LMN nuclear CPA meatal lanyrinthine horizontal tympanic vertical mastoid
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Motor LMN nuclear CPA meatal lanyrinthine horizontal tympanic vertical mastoid SM foramen
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Motor LMN nuclear CPA meatal lanyrinthine horizontal tympanic vertical mastoid SM foramen peripheral
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Motor LMN nuclear CPA meatal lanyrinthine horizontal tympanic vertical mastoid SM foramen peripheral
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Relations & LMN branches nuclear )6 N( th
N(
CPA )cerebellum & N intermedius & 8TH meatal )8th N(
LMN branches level greater petrosal N to stapedius chorda tympani peripheral
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Disorders of the facial nerve
Motor dysfunction hypokinetic hyperkinetic blepherospasm & facial tics hemifacial spasm facial myokymia focal siezure synkinesia tic doulaureux )trigeminal nueralgia( Autonomic crocodile tears sphenopalatine neuralgia Sensory herpes zoster otalgia Bell s palsy taste disturbance
Pathophysiology
Idiopathic
mostly viral
Traumatic Inflammatory neoplastic Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Pathophysiology
Neuropraxia Axontemesis neurotmesis Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Sunderland classification of peripheral nerve injury Neurapraxia
Axonotmesis
Neurotmesis
Pathophysiology Wallerian degeneration Absent in neuripraxia
Occurs in
axontemesis neurontesis
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Pathophysiology Wallerian degeneration Absent in neuripraxia
Occurs in
axontemesis neurontesis
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Pathophysiology
Neuropraxia Axontemesis neurotmesis Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Pathophysiology Regeneration Intact sheath good recovery
Disrupted sheath
failure )residual paralysis + atrophy( misdirection to other muscles)synkinesia( taste to lacrimal gland )crocodile tears( parotid fibres to sweat glands )frey syn to other axons)short circuiting(
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
TESTS OF THE FACIAL NERVE
Site of lesion)topognostic( Electrodiagosis )prognostic( Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
TESTS OF THE FACIAL NERVE Site of lesion)topognostic( 1-G petrosal N schirmer test 2-N to stapedius stapedial reflex 3-chorda tympani a(taste gustometry b(salivary flow 5-peripheral brabches segmental facial movement Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
TESTS OF THE FACIAL NERVE Site of lesion)topognostic( 1-G petrosal N schirmer test 2-N to stapedius stapedial reflex 3-chorda tympani a(taste gustometry b(salivary flow 5-peripheral brabches segmental facial movement Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Topognostic Test • Lacrimal – Schirmer’s Test
• Stapedial reflex • Taste • Salivary flow
TESTS OF THE FACIAL NERVE Electrodiagosis )prognostic( 1-nerve excitability test
3.5 mA difference is significant
2-strength duration curve normal, partial or denervation curves
3--maximal N stimulation test 4 electromyography voluntary,fibrillation denervation or polyphasic reinnervation potentials
5-electroneurography the most informative
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
TESTS OF THE FACIAL NERVE
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
TESTS OF THE FACIAL NERVE Electroneurography the most informative quantitative
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Diagnosis Paralysed or not? Where is the lesion? How much is the degeneration? What is the lesion?
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
1-Paralysed or not? Clinical picture
At rest Voluntary movement Emotional movement Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Clinical picture At rest
)Due to unoppoesd pull of active muscles(
Loss of Forhead whrinkes Nasolabial fold Dead wide Eye Mouth Dropped angle Shortened on active
side
drippling from angle
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Clinical picture
Voluntary movement During eating During talking ask him to Whrinkle forehead Raise eyebrow Close the eye Show your teeth Blow your cheek To whistle
Emotional movement Prof. Hisham Hamad Copyright, 1996 © Dale Carnegie & Associates, Inc.
Clinical picture
During Close the Blow the Show th voluntary eyes teeth cheek movement
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
2-Where is the lesion UMNL or LMNL LMNL what level nuclear CPA meatal at geniculate( suprapyramidal infrapyramidal at stylomastoid F extratemporal
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
UMNL # LMNL Site of lesion Side of paralysis Emotional movement Upper face movement Type of lesion Sequllae of paralysis Bell s phenomenon Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
2-Where is the lesion UMNL or LMNL LMNL what level nuclear CPA meatal at geniculate( suprapyramidal infrapyramidal at stylomastoid F extratemporal
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
2-Where is the lesion UMNL or LMNL LMNL what level nuclear CPA meatal at geniculate( suprapyramidal infrapyramidal at stylomastoid F extratemporal
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
2-Where is the lesion UMNL or LMNL LMNL what level nuclear CPA meatal at geniculate( suprapyramidal infrapyramidal at stylomastoid F extratemporal
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
2-Where is the lesion? topognostic tests 1-G petrosal N schirmer test 2-N to stapedius stapedial reflex 3-chorda tympani a(taste gustometry b(salivary flow 5-peripheral brabches segmental facial movement
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
2-Where is the lesion
UMNL or LMNL LMNL
AR(
nuclear )6th N+ hemiplegia + all Normal( CPA )cerebellum+ 8TH N + N intermedius( meatal )No celebellar( at geniculate)No 8TH N( tympanic )Normal tearing( mastoid )Normal tearing & N at stylomastoid F )all Normal( extratemporal )segmental(
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
3-How much
degeneration Degree does not matter Incomplete paralysis always recovers well Complete paralysis recovers well if neuropraxic if degeneration is less than 90% Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
3-How much
degeneration Elecrodiagnostic tests Elecroneurography test
IS THE MOST VALUEBLE QUANTITATIVE 90 % or less degeneration denotes poor recovery
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
4-What is the lesion ? Idiopathic Inflammatory
malig OE AOM, A mastoiditis ch OM, H zoster
Traumatic F base, forceps cut wound Iatrogenic brain, ear, parotid Neoplastic primary 2ndary Toxic metabolic
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
4-What is the lesion ? Idiopathic Inflammatory
malig OE AOM, A mastoiditis ch OM, H zoster
Traumatic F base, forceps cut wound Iatrogenic brain, ear, parotid Neoplastic primary 2ndary Toxic metabolic
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
4-What is the lesion ? Idiopathic Inflammatory
malig OE AOM, A mastoiditis ch OM, H zoster
Traumatic F base, forceps cut wound Iatrogenic brain, ear, parotid Neoplastic primary 2ndary Toxic metabolic
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Complications Psychological Drooling Eye complications exposure keratitis infection )up to panophthamitis( Persistent paralysis Tics & spasm Atrophy & contracture Crocodile tears Frey syndrome
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Treatment:
Of the cause
Avoid complication
Avoid complication eye muscle atrophy residual paralysis Treat established complications residual paralysis crocodile tears $ gustatory sweating
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Treatment:
Avoid complication
Of the cause antibiotic in malignant OE Acyclovir if viral )H zoster & Bell s( myringotomy if early in AOM mastoidectomy if late in AMO mastoidectomy if in chronic MO Avoid complication Treat established complications
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Treatment:
Of the cause
Avoid complication
Avoid complication eye
glasses
artificial tears & ointment & dark tarsorraphy or
gold weight
implant muscle atrophy adhesive tape phsiotherapy )passive $ active( residual paralysis medically steroid surgical if more than 90% deg decompression reanastonosis grafting
Treatment:
Avoid complication
Treatment: Surgery Guidelines If partial If complete tests degeneration
No surgery do elecrodiagnosis till till
recovery 90%
if more than 90% degeneration do decompression )partial injury( reanastomosis )complete injury( nerve grafting )tissue loss(
Treatment: eye Avoid eye complication artificial tears ointment tarsorraphy gold weight implant
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Prof. Hisham Hamad
Gold weight implanta tion
Treatment: Avoid complication Of the cause Avoid complication Treat established complications
residual paralysis reanimation )if irreversible( dynamic graft facio-facial )cross face( hypoglossal to facial free micro-neurovascular static )sling( facia lata temporalis muscle masseter muscle crocodile tears $ gustatory
Dynamic reanimatiom graft
facio-facial )cross face(
hypoglossal to facial
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Dynamic reanimatiom free micro-neuro-vascular
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
static reanimatiom
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Bell s palsy Definition:: idiopathic+ unilateral+ LMNL of the facial nerve Aetiolgy: Idiopathic Ischeamia primary )cold( 2ary)viral or autoimmune( Polymerase chain reaction )PCR( have demonstrated herpetic infection in most of the ceses. A better term is viral or herpetic facial paralysis.
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Diagnosis:
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Treatment:
prognosis
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Treatment:
No treatment for partial paralysis Complete paralysis give : Cortisone Acyclovir VD ?? + neurotropic vitamins ?? Surgical decompression if degeneration exceeds 90% physiotherapy afterv 2 weeks dark glasses + eye ointment +adhesive tapes Prof. Hisham Hamad Copyright, 1996 © Dale Carnegie & Associates, Inc.
Problem solving and MCQ Questions
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
•What is the lesion? •Side)Rt or Lt( •Site )U or lower(
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
•What is the lesion? •Side)Rt or Lt( •Site )U or lower(
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
•What is the lesion? •Side)Rt or Lt( •Site )U or lower(
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
•What is the lesion? •Side)Rt or Lt( •Site )U or lower(
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Problem solving
• This gentleman presented with right severe otalgia and drippling of saliva from the right side of the mouth with collection of food in the right cheek during meals. No other associated symptoms or sign were noted.
• What is the most probable diagnosis?
Prof. Hisham Hamad
Problem solving
• This gentleman is 50 ys old presented with one day history of “my face isn’t moving” – Occurred overnight – No ear pain, previous viral illness – No hearing loss – No prior history, no family history – No other associated symptoms
• 4 weeks he started to feel some movement in his face.
• What is the most probable diagnosis?
Prof. Hisham Hamad
• Recurrent Facaial paralysis occurning few days after onset of acute otitis media denotes A.Bulging tympanic membrane B.Mastoiditis C.Congenital anomaly of the ear D.Immunodefiency
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
•Bells balsy is commonly treated with: A( antihistaminic and steroids B( antihistaminic and antiviral C( antiviral And steroids D( antibiotic and steroids
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
•Progressive unilateral LMN Facaial paralysis over more than 3 monthes without identified aetiology is most probably due to •A( Bell s balsy
•B( Brain tumor in motor area of temporal tempora lobe •C Acoustic nerve neuroma •D( Malignant otitis externa
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
1. Most prescribe steroids. The benefit is controversial. Conversely, 60mg of Prednisone for 7-10 days has only minor risks 2-The prognosis is so poor for Herpes Zoster Oticus cases that specialty consultation is required for patient satisfaction )that all possible was done( and for the PCP's medical legal protection. 3-Possible Lyme disease in endemic areas
Prof. Hisham Hamad
Copyright, 1996 © Dale Carnegie & Associates, Inc.
Prof. Hisham Hamad
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