6.3 Facial Palsy PDF

6.
3 FACIAL PALSY Anatomy of the facial nerve The facial nerve supplies the structures derived from the second branchial arch. It is the seventh cranial nerve and is motor to the muscles of facial expression. It originates from the pontine region of the brain stem and enters the temporal bone at the internal auditory meatus, alongside the eighth cranial nerve. It emerges as two routes the larger motor route and the smaller nervus intermedius that carry taste and parasympathetic and sensory fibres It traverses the internal acoustic meatus, facial canal and parotid gland Within facial canal, it gives off: 1. Greater petrosal nerve secretomotor tear secretion from the lacrimal gland and glands of palate 2. Tympanic nerve small sensory branch 3. Nerve to stapedius acts to dampen loud noises. 4. Chorda tympani supplies taste to the ant 2/3 of the tongue, travels with the lingual nerve.
It then emerges from the stylomastoid foramen: 1. Posterior auricular nerve occipital muscles and sensation to small area behind earlobe. 2. Nerve to posterior belly of digastric and stylohyoid Then divides into upper temporozygomatic branch and lower cervicofacial branch. Within the substance of the parotid gland each branch divides and rejoins only to divide again into the 5 terminal branches.
1. Temporal (frontal) travels along Pitanguys line from 0.5 cm below the tragus to 1.5cm above and lateral to the eyebrow. The frontal branch becomes increasingly superficial as it travels upwards. It lies just deep to the temporoparietal (superficial temporal) fascia in the temple. Lower motor neurone lesions of the facial nerve or its frontal branch result in paralysis of the ipsilateral frontalis muscle. 2. Zygomatic branch divides into branches supplying the orbicularis oculi muscle, division results in an inability to close the eye.
Last printed 11/03/2012 00:22:00 -1 C:\Users\Zeeshan\Documents\My Dropbox\frcs(plast) notes and papers\Reinstalled frcsplast.com\1. FRCS(Plast) Revision Notes\06. Ear Eyelid Nose & Vasc Anomalies\6.3 Facial Palsy.doc
3. Buccal branch divides into multiple branches travelling along side the parotid duct supplying the buccinator and the muscles of the upper lip. Division causes trouble emptying the cheek. 4. Marginal Mandibular runs just below the border of the mandible deep to the platysma and superficial to the facial vein. It supplies the muscles of the lower lip. Division of this nerve results in elevation of the corner of the mouth. 5. Cervical Branch runs downwards into the neck to supply the platysma. There is a significant degree of crossover between the buccal and zygomatic branches so can get some crossover innervation, little crossover for the frontal or marginal mandibular.
Congenital VII Palsy - Neonatal Facial Paralysis Obstetric facial paralysis - forceps Mbius syndrome1888 Defect in development of facial nucleus 6th and 7th nerve palsies Paralysis of VII and VI characterised by bilateral facial paralysis May also involve III, V, IX and XII Limb abnormalities present in 25% Pectoral abnormalities present in 15% MVH avoid nerve grafts and use LD, IX as donor nerve to attach LD n directy on to. CLUFT abnormalities in Mobius - Abrahams PRS 1988 Cranial nerves Lower Limb Upper limb Facial Thoracic Treatment of Mbius Syndrome Cant use other site for source of nerve innervation so use another nerve for innervation of free muscle transfer. Ipsilateral accessory, Trigeminal, ipsilateral hypoglossal but often abnormal so not suitable
Goldenhars syndrome Hemifacial microsomia Epibulbar dermoids May have assoc facial nerve abnormality Acquired Facial Paralysis Causes of Facial Palsy Systemic Causes o Pregnancy o DM o hypo/hyper thyroid o lead o tetanus o diphtheria o carbon monoxide Central Causes o Intracranial - tumour/trauma/congenital Tumours - CNS Masses, Extracranial Masses - parotid, cholesteatoma Multiple Sclerosis Polio Mbius Intratemporal o Bells palsy o Trauma, incl. iatrogenic o Otitis media o Cholesteatoma o Acoustic Neuroma o Infection - Herpes Zoster oticus (Ramsay Hunt Syndrome) o Tumours of middle ear Extratemporal o Trauma o Tumours of the facial nerve, maxilla/mandible o Parotid Malignancy - esp. acinic cell- perineural inv o Iatrogenic injury
Bells Palsy (Charles Bell 1814) Originally facial palsy from any cause now idiopathic only, diagnosis of exclusion. 10% labelled with this have other cause May be caused by a viral infection producing swelling of the nerve within its tight intratemporal course. 1/60 lifetime risk, 20/100,000 90% full or nearly full recovery (50% full) - incomplete paralysis is a good sign Most patients regain full facial nerve function and usually start to improve after 4 weeks. In severe cases complete axonal degeneration occurs taking 3 months to signs of recovery and may be incomplete.
Facial Palsy Assessment loads out there House & Brackman Scale o Graded 1-6: o Essentially: Normal-Mild-Mod-Severe-Very Severe-Total. Facial grading scale (Ross) Facial Disability Index Burres Fisch - Lots of numbers Nottingham Score - Jonathan Britto likes it. Or use MRC grade House and Brackman (in more detail): Grade 1 some mimetic (spontaneous) movement Grade 2 no mimetic Grade 3 only mass action of facial muscles Grade 4 unable to completely close eyelids Grade 5 symmetry despite complete paralysis Grade 6 an asymmetrical face with no movement Evaluation History - insidious vs. rapid Blunt vs. sharp trauma Assess Bells Phenomenon! Protect the eye! Total vs. Partial, unilateral vs bilat, symmetry at rest and dynamic there will be some residual function almost always. Look for synkinesis and areas of over-innervation Cranial N. examination Brow ptosis/Ectropion(late)/Oral incompetence NL Fold/Malar prominence asymmetry Nasal tilt - scoliosis - away from affected side Scars or signs of previous trauma, Absence of forehead wrinkles, Position and movement of upper lid Condition of the conjunctiva for evidence of exposure Ectropion of lower eyelid Position of the mouth Test strength of eyelid closure Perform eyelid SNAP test Assess nasal valving Verify that temporalis is contracting by palpating as the pt clenches jaw. Investigation Electroneuronography - like EMG but compare to normal side - assessed over time Schirmers Tear Production integrity of greater petrosal nerve by measuring the tear production. Special filter paper in lower conjunctiva for 5 mins. <10mm of wetting is abnormal. Local anaesthetic can be added to block the reflex tear secretion then called Schirmers test 2. Stapedius reflex test tests the integrity of the facial nerve branch to stapedius. Taste test ant 2/3 of tongue integrity of the chorda tympani. Treatment Non op vs. op Dynamic vs. static Functional vs. Free Muscle
Goals of Treatment Rest symmetry Facial function Voluntary function Spontaneous movement Absence of synkinesis Non-operative treatment Protection of the eye - Bells Phenomenon is present in 75% - lubricating drops, glasses, taping closed at night Paralytic ectropion lateral taping Botox (clostridium botulinum) produces paralysis by interfering with the release of acetylcholine from the motor nerve endplates. Botox to normal side of face can improve symmetry. High dose steroids within 72hrs ineffective after 7 days Antivirals Static Operations Tarsorrhaphy Narrows the palpebral fissure by joining the eyelids aides eye closure Temporary Tarsorrhaphy Performed when there is some expectation of recovery o Central Frost Suture lower eyelid suture held to forehead with Steristrips o Lateral Permanent Tarsorrhaphy - if little expectation of recovery o McLaughlin Tarsorrhaphy o Post flap from lower lid o Ant from upper o Outer 1/3 o Lash preserving Kuhnt-Symanowski Procedure o Split level eyelid resection differential wedge excisions from anterior and posterior lamellae (see 6.2.1 Ectropion) o Used to correct paralytic ectropion of the lower eyelid o Largely obsolete now. Gold Weights/springs o Inserted into the upper lid to help closure placed subcutaneous over the orbicularis. o Customised vs. off the shelf o With/without anchoring hole o Trial first by taping on to outside to get weight right Brow Lifts / Suspension o Endoscopic or open, elevate the ptotic brow caused by paralysis of frontalis Forehead Skin excision o Skin excision above the eyebrow or in the temple Unilateral facelift type procedures o Remove skin excess and improve facial symmetry o subperiosteal lift with lower lid rebalancing o thread-lift, Endotine lift etc. Facial slings o Segments of fascia lata to elevate the corner of the mouth and nose. o Fascia Lata on to temporalis
Dynamic Procedures Nerve repair or graft Direct repair of damaged or cut nerves good functional recovery if optimal conditions. Graft if gap >2cm - Gt. auricular or sural Cross-facial nerve grafting (Scaramella 1970) Sural nerve graft anastomosed to branch of the facial on the non affected side distal stump of the facial nerve on damaged side. One or 2 stage op, 2 stage excise terminal neuroma after waiting for Tinels to cross face then attaching to distal stump limited success as the facial muscles wont reinnervate after the delay Nerve Transfers/Substitution Other nerves onto the distal stump, Glossopharyngeal, Hypoglossal, Accessory, Phrenic. Easy to perform, only need to cross one anastomosis, but only produce course movements, loose function of donor nerve. Hypoglossal often used after tumour resection. Avoid babysitting denervation of tongue Muscle Shortening or Local muscle flaps Muscle Shortening if partially affected Masseter part or all can be transf erred, divided into 3 slips and insert above the lip, into the commissure and below the lip. Temporalis transposed and inserted around the eye, need extra periosteal extensions or fascial grafts to elongate the muscle see EG technique below SCM described but rarely used. Cross face nerve grafting and free-muscle transfer One or 2 stage procedure. One stage muscle with long donor nerve, only have one suture line, no nerve graft donor but not many suitable muscles, long denervation time of the muscle results. Two stage Reversed sural nerve graft tunnelled from donor buccal branch nerve to tragus. After nerve regeneration free muscle harvested and inserted onto Zygomatic arch and distally to the mouth and nose. Positioning aims to replicate the function of zygomaticus major. Use gracilis, pectoralis minor, or LD. Mount Vernon Technique - Dougie Harrison + Grobelaar Prefer dynamic techniques: o 2 stages - mean 8m apart o 471 cases as of Jan 06 o Pec minor 1st choice - 3 slips into upper lip, lower lip, alar base. o EDB occasionally. o Gracilis never Julia Terzis says - Pec minor is a 'clever' muscle - small motor units. LD is stupid Manfred Frey says - need 3rd stage fiddles East Grinstead Technique Charles Nduka early experience (June 07) Functional muscle transfer: o Prefers temporalis techniques adapted from Fausto Viterbo (Brazil) and Daniel Labbe (Caen, France) o (Fausto Viterbo proved can do end-side nerve anastomosis)
Temporalis transfer Retrograde (mid portion only taken - criticised as the muscle is now trying to raise mandible as well as raise smile - relatively opposing actions Orthograde - McLaughlin - coronoid process insertion detached and transferred with tendon graft Orthodromic in-line transfer of temporalis: Daniel Labb - PRS 1996 - bicoronal approach, zygomatic arch x2 osteotomies, coronoid detached tunnelled through fat pad to avoid skin-tether, insertion beyond NL-fold - no tendon graft - i.e. both insertion and origin are released (nerve stim used to check). Now using cross-face graft to help sync of both sides Reliable surface marker - Base of nose to tragus - 2cm anterior to tragus is Zygomatic branch
Charles Ndukas criticisms of Free Muscle Transfer o Pec minor - only Grobelaar in UK o 2-stage, so slower rehab o Bulky o nerve often does not reach in kids - head relatively big c.f. muscle, o long interval from start of surgery to facial movements appearing
Results: Mike Poole's Hay's Score vs Dougie Harrisson's PRS 1985 - 1,2,3 score younger get better results. ???
Facial Palsy Ophthalmology Cornelius Rene Manchester 23 Mar 07 Problems Corneal exposure Paralytic ectropion Epiphora Poor cosmesis Assessment Vertical palpebral aperture Lagophthalmos inability to close eye completely Lid position Lower Lid laxity Corneal exposure Corneal sensation Bells Phenomenon Brow Ptosis

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