Ear, Nose & Throat and Head & Neck Surgery

1. Dr. Zaimal Shahan
Post Graduate Trainee
ENT DEPARTMENT
CAPITAL HOSPITAL

2. Anatomy

3. Anatomy

4. Anatomy

5. Anatomy

6. Type of Fibers
 Facial nerve is a mixed nerve, having a motor
root and a sensory root.
 Motor root supplies all the mimetic muscles of
the face which develop from the 2nd
brachial
arch.

7.  Sensory root “nerve of Wrisberg” carries taste
fibers from the anterior 2/3 of the tongue and
general sensation from the concha and
retroauricular skin.
 Also it carries secretomotor fibers to the
lacrimal, submandibular and sublingual
glands as well as those in the nose and
palate.

8. Nuclei
 Motor nucleus of facial nerve (SVE):
It lies in the lower part of the pons
 Superior salivatory nucleus (GVE):
It lies in the pons lateral to the main motor
nucleus of VII and gives rise to secretomotor
parasympathetic fibers that pass in
greater superficial petrosal nerve and
chorda tympani.

9.  Nucleus solitarus (SVA):
It lies in the medulla, receives the taste
sensation from the anterior 2/3 of the tongue via the
central processes of the cells of the geniculate
ganglion of the facial nerve
 GSA fibers :
Through these fibers to acoustic meatus & back
of auricle through communication from auricular
branch of vagus. These fibers terminate in main
sensory nucleus & spinal nucleus of 5 th nerve

11. Nucleus xxxx
 Pons.
 precentral gyrus.
 Upper part of the nucleus:
 Upper face
 Involuntary emotional movements

12. Course
 Motor fibers originate…
 Hooks around the abducent nucleus in the floor of the
4th ventricle forming facial colliculus
 Joined by…
 Facial n. leaves the brainstem…
 Travels through…
 Enters the IAC.
 Then traverse the temporal bone through facial n.
canal
 Leaves the temporal bone through
 Finally divides into terminal branches.

13. Internal course: the motor fibres passes dorsally and
medially forming a loop around the abducent nucleus in
the floor of the 4th ventricle forming facial colliculus
COURSE OF FACIAL NERVE
xxxx
Superficial origin: at the pontomedullary angle above
the inferior cerebellar peduncle.

14. 1- Facial nerve proper (motor): arising from facial
motor nucleus in pons.
2- Nervus intermedius: it is the sensory root of facial
lies position between the facial proper and
vestibulcochlear nerve in the pontocerebellar angle.
Carrying para-sympathetic fibers (from superior
salivary nucleus) and taste fibers ( to the solitary
nucleus).
The facial nerve is formed mainly of two parts:

15. Course and relations:
I- Intracranial (intrapetrosal) course
II- Extracranial course

16. I- The intrapetrous course:
A.Meatal segment
B.Labyrinthine segment
C.Tympanic segment
D.Mastoid segment

17. A.MEATAL SEGMENT

8-10 mm

18. B.LABYRINTHINE SEGMENT
3.5-4.0mm
Obliquely forward
Perpendicular to temporal bone
NARROWEST PART
Changes direction----- 1st
GENU
GENICULATE GANGLION:
Junction of FACIAL NERVE+NERVUS
INTERMEDIUS

19. II- Extracranial course:
 As it emerges from the stylomastoid foramen, it runs
forwards in the substance of the parotid gland crosses
the styloid process, the retromandibular vein and the
external carotid artery.
It divides behind the neck of the mandible into its
terminal branches which come out of the anteromedial
surface of the gland.

20. BRANCHES
1.PETROSAL NERVES
2.GREATER SUPERFICIAL
PETROSAL NERVE
3.LESSER PETROSAL NERVE
4.EXTERBNAL PETROSAL NERVE

21. Parts
 Intracranial part
 Intratemporal part
 Extracranial part

22.  Intratemporal segments
 Meatal
 Labyrinthine
 Tympanic, horizontal
 Mastoid, vertical

23. Branches
 Greater superficial petrosal nerve:
 Nerve to stapedius:
 Chorda tympani:
 Comunicating branch:
 Posterior auricular nerve:
 Muscular branches:
 Peripheral branches: “Pes anserinus”
 Temporal
 Zygomatic
 Buccal
 Marginal Mandibular
 Cervical

33. Surgical landmarks
 Middle Ear and Mastoid Surgery:
 Processus chocleariformis
 Oval window and horizontal canal
 Short process of the incus
 Pyramid

34.  Parotid Surgery:
 Cartilaginous pointer:
 Styloid process
 Posterior belly of digastric muscle
 Tympanomastoid suture

35. Anatomy: Structure of the nerve
 From inside outward:
 Axon
 Myelin sheath
 Neurolimma
 Endoneurium
 Perineurium
 Epineurium

38. Branches
Branches of
communication
Branches of distribution

39. Internal acoustic
meatus
Vestibulocochlear
nerve
Geniculate ganglion A. Greater petrosal
nerve
B. Lesser petrosal
nerve
C. External
petrosal nerve
Facial canal Vagus nerve
Stylomastoid foramen IX & X cranial nerve
Branches of Communication

42. Branches of Distribution
Facial canal
A.Nerve to stapedius
B.Chorda tympani
In face
A.Temporal
B.Zygomatic
C.Buccal
D.Marginal mandibular
E.Cervical
Stylomastoid
foramen
A.Posterior auricular
B.Nerve to stylohyoid
C.Nerve to digastric
(posterior belly)

43. Facial Nerve: Functional Components
 Special Visceral Efferent/Branchial Motor
 General Visceral Efferent/Parasympathetic
 General Sensory Afferent/Sensory
 Special Visceral Afferent/Taste

44. Special Visceral Efferent/Branchial
Motor
 Premotor cortex  motor cortex 
corticobulbar tract  bilateral facial motor
nuclei (pons)  facial muscles
 Stapedius, stylohyoid, posterior
digastric, buccinator

47. GANGLIA ASSOCIATED WITH
THE FACIAL NERVE
 Geniculate ganglion
 Submandibular ganglion
 Pterygopalatine ganglion

48. Geniculate Ganglion
 The geniculate ganglion (from Latin genu, for "knee")
is an L-shaped collection of fibers and sensory
neurons of the facial nerve located in the facial canal
of the head.
 It receives fibers from the motor, sensory, and
parasympathetic components of the facial nerve and
sends fibers that will innervate the lacrimal glands,
submandibular glands, sublingual glands, tongue,
palate, pharynx, external auditory meatus, stapedius,
posterior belly of the digastric muscle, stylohyoid
muscle, and muscles of facial expression.

50. Submandibular Ganglion
 The submandibular ganglion is small and fusiform in
shape. It is situated above the deep portion of the
submandibular gland, on the hyoglossus muscle,
near the posterior border of the mylohyoid muscle.
 The ganglion 'hangs' by two nerve filaments from the
lower border of the lingual nerve (itself a branch of
the mandibular nerve, CN V3). It is suspended from
the lingual nerve by two filaments, one anterior and
one posterior. Through the posterior of these it
receives a branch from the chorda tympani nerve
which runs in the sheath of the lingual nerve.

52. Pterygopalatine Ganglion
 The pterygopalatine ganglion (meckel's
ganglion, nasal ganglion or sphenopalatine
ganglion) is a parasympathetic ganglion
found in the pterygopalatine fossa.
 It's largely innervated by the greater petrosal
nerve (a branch of the facial nerve); and its
axons project to the lacrimal glands and nasal
mucosa

54. Testing of Facial Nerve Branches
 Testing the temporal branches of the facial
nerve
 To test the function of the temporal branches
of the facial nerve, a patient is asked to frown
and wrinkle his or her forehead.
 Testing the Zygomatic branches of the facial
nerve
 The patient is asked to close their eyes tightly.

55.  Testing the buccal branches of the facial
nerve
 Puff up cheeks (buccinator)
 Smile and show teeth (orbicularis oris)
 Tap with finger over each cheek to
detect ease of air expulsion on the
affected side

56.  The marginal mandibular nerve may be
injured during surgery in the neck region,
especially during excision of the
submandibular salivary gland or during
neck dissections.

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

60. Central facial paralysis
 Upper motor neuron 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

61. Peripheral paralysis
 Lower motor neuron 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

63. 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

64. TOPOGNOSTIC TESTING
1. Schirmer test for lacrimation (GSPN)
2. Stapedial reflex test (Stapedial branch)
3. Taste testing (Chorda tympani nerve)
4. Salivary flow rates & pH (Chorda tympani)
ELECTROPHYSIOLOGIC TESTS
Nerve excitability test (NET)
Electromyography(EMG)
Maximal stimulation test (MST)
Electroneuronography (ENoG)
DYES
Testing of Facial Nerve

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

66. Schirmer's Test
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

67. Schirmer's Test

68. Stapedius reflex
Nerve to stapedius muscle test
Impedence 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

69. Taste (Electrogustometry)
Chorda tympani nerve test
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

70. Maximum stimulation Test: MST:
Indication: complete paralysis<3wks
Interpretation:
Marked weakness or no muscle contraction:
advanced degeneration with guarded prognosis

71. Electroneurography: ENoG
Indication: complete paralysis<3wks
Interpretation: < 90% degeneration: prognosis is
good; > or = 90%: prognosis is a question
Limitation: False-positive results in deblocking phase.

73. Electromyography: EMG
Indication: Acute paralysis less than 1 week or chronic
paralysis longer than 2 weeks
Interpretation:
Active mu: intact motor axons
Mu + fibrillation potentials: partial degeneration
Polyphasic mu: regenerating nerve
Limitation: cannot assess degree of degeneration or
prognosis for recovery

74. Anatomy: Severity of injury
 Saunderland classification:
 1°: Partial block: Neuropraxia
 2°: Loss of axons: axonotemesis
 3°: Injury to the endoneurium: neurotemesis
 4°: Injury to the perineurium: partial
transection
 5°: Injury to the epineurium: complete
transection

75. History:
 Onset: Sudden vs. Gradual
 Duration:
 Rate of progression:
 Recuurent or familial
 Associated symptoms
 Medical history
 Previous surgeries

76. Physical exam:
 Complete vs. incomplete
 Segmental vs. uniform involvement
 Unilateral vs. bilateral
 Cranial nerves assessment
 Neurologic evaluation
 Cerebellar signs

77. Physical exam:
 Microscopic otoscopy
 Complete head and neck exam

78. Physical exam:
 Localization of facial nerve lesion:
 Central vs. Peripheral.

79. Physical exam:
 Localization of facial nerve lesion:
Peripheral:
 Level of nucleus
 CPA level:
 Bony canal level: Topodiagnostics
 Outside the Temporal bone

80. Physical exam:
 Topodiagnostics:
 Schirmer’s test:
 Stapedial reflex:
 Taste test:
 Submandibular salivery flow test: Warton’s
ducts

81. Causes:
 Central:
 Intacranial part:
 Intratemporal part:
 Extracranial part:
 Systemic:

82. Disorders of Facial
Nerve
1. Supra nuclear type:
Features:
a) Paralysis of lower part of face (opposite side)
b) Partial paralysis of upper part of face
c) Normal taste and saliva secretion
d) Stapedius not paralysed
Facial Nerve Lesions

86. 2. Nuclear type:
Features:
a) Paralysis of facial muscle
(same side)
b) Paralysis of lateral rectus

87. 3. Peripheral lesion
A.INTRACRANIAL(CPA)
Acoustic neuroma
Meningioma
Congenital cholesteatoma
Metastatic carcinoma
Meningitis

88. B.INTRATEMPORAL
1.IDIPOPATHIC
BELL PALSY
MELKERSON SYNDROME

89. 2.INFECTIONS:
ASOM
CSOM
HERPES ZOSTER OTICUS
MALIGNANT OTITIS EXTERNA

90. 3.TRAUMA:
A.SURGICAL:
Mastoidectomy + Stapedectomy
B.ACCIDENTAL:
Fracture TB

91. D.NEOPLASTIC:
Malignancies
Glomus jugulare
Facial nerve neuroma
Metastasis to temporal bone

92. B.EXTRACRANIAL
Parotid malignancy
Parotid surgery
Accidental trauma
Neonatal trauma

93. Lesion at int
acoustic meatus

94. SYSTEMIC DISEASES
DM
Hypothyroidism
Uraemia
Sarcoidosis
Leprosy
Leukemia
Demyelinating diseases

95. Lesion
distal to
geniculate
ganglion

97. A.IDIOPATHIC

98. 1.BELL PALSY
First described more than a
century ago by Sir Charles Bell

99. Demographics of Bells palsy
Race: slightly higher in persons of Japanese descent.
Sex: No difference exists
Age: highest in persons aged 15-45 years.
Bell palsy is less common in those younger than 15 years
and in those older than 60 years.

100. Pathophysiology of Bells palsy
IDIOPATHIC
1.ISCHEMIC THEORY
2.VIRAL THEORY
3.AUTOIMMUNE THEORY

101. Bell's phenomenon is the upward diversion of
the eye ball on attempted closure of the lid is seen
when eye closure is incomplete.

102. Features of Bell’s Palsy

103. Fore head

104. Diagnosis of Bells palsy
By exclusion
Criteria
Paralysis or paresis of all muscle groups of one side of
the face
Sudden onset
Absence of signs of CNS disease
Absence of signs of Ear disease

105. Medical treatment
Corticosteroids :
Prednisolone 1 mg/kg/day 7-10 days
Corticosteroids combine with antiviral drug is better
Acyclovir 400 mg 5 times/day
Famciclovir and valacyclovir 500 mg bid

106. Surgical treatment
Facial nerve decompression
Indication:
Completely paralysis
ENoG less than 10% in 2 weeks
Appropriate time for surgery is 2-3 weeks after paralysis

107. 2.MELKERSSON SYNDROME
A.FACIAL PARALYSIS
B.SWELLING OF LIPS
C.FISSURED TONGUE

108. B.INFECTIONS

109. RAMSAY HUNT SYNDROME
HERPES ZOSTER OTICUS

110. Symptoms:
Facial
paralysis
Ear pain
Vesicles
Herpes zoster oticus
Ramsay Hunt syndrome type II

111. Moebius syndrome (congenital facial diplegia)
Abnormal VI ,VII,XII Nerve nuclei
Facial Nerve absent / smaller
Congenital Extra ocular muscle & facial palsy
Congenital Facial nerve palsy

112. Cardiofacial Syndrome
Unilateral facial paralysis involving only the lower lip
and congenital heart disease
 The facial paralysis in these patients involves only
those muscles concerned with pulling the lower
lip downwards and outwards
 These are the
mentalis, depressor labii inferioris and depressor
anguli oris muscles

113. All are supplied by the mandibular marginal branch of
the facial nerve.
Lesions of this nerve have been recognized in adults
and children for many years
The paralysis is only recognizable when the patient
talks, smiles or cries

114. Treacher collins syndrome
(mandibulo facial dysostosis)
There is a set of typical symptoms within Treacher Collins
Syndrome
The OMENS classification was developed as a
comprehensive and stage-based approach to differentiate
the diseases.
O; orbital asymmetry
M; mandibular hypoplasia
E; auricular deformity
N; nerve development and
S; soft-tissue disease

115. Facial Nerve involvement in
Treacher collins syndrome
N0: No facial nerve involvement
N1: Upper facial nerve involvement (temporal or
zygomatic branches)
N2: Lower facial nerve involvement (buccal,
mandibular or cervical)
N3: All branches affected

116. Goldenhars syndrome
(oculoauriculo vertebral dysplasia)
It is a wide spectrum of congenital anomalies that
involves structures arising from the first and second
branchial arches.
Features of hemi facial microsomia, anotia, vertebral
anomalies, congenital facial nerve palsy.

117. C.TRAUMA

118. 1.FRACTURES TEMPORAL BONE
LONGITUDNAL
TRANSVERSE
MIXED

119. IMMEDIATE ONSET:
SURGICAL
DECOMPRESSION
RE-ANASTOMOSIS
CABLE NERVE GRAFT
DELAYED ONSET:
TREAT LIKE BELL PALSY

120. 2.EAR/MASTOID SURGERY

121. 3.PAROTID SURGERY

122. D.NEOPLASMS
1.INTRATEMPORAL
2.TUMORS OF PAROTID

123. E.CONGENITAL
 Facial Nerve Injury from Birth Trauma
 Trauma (forceps delivery)
 Congenital Facial Palsy
Mobius syndrome
Cardiofacial syndrome

124. Toxic Causes:
 Thalidomide
 Tetanus
 Diphtheria
 Carbon Monoxide
 Lead Intoxication

125. Causes:
 Central:
 Brain abscess
 Pontine glioma
 Poliomyelitis
 Multiple sclerosis

126. Causes:
 Intacranial part:
 Acoustic neuroma
 Meningioma
 Metastatic CA
 Meningitis

127. Causes:
 Intratemporal part:
 Idiopathic:
 Bell’s palsy
 Melkersson’s syndrome

128. Causes:
 Intratemporal part:
 Infections:
 ASOM
 CSOM
 Herpes Zoster Oticus

129. Causes:
 Intratemporal part:
 Trauma:
 Surgical: Mastoidectomy, Stapedectomy
 Accidental:# temporal bone

130. Causes:
 Intratemporal part:
 Neoplasms:
 Glomus jugulare tumour
 Facial nerve neuroma
 Metastatic CA

131. Causes:
 Extracranial part:
 Parotid gland CA
 Parotid gland surgery
 Parotid gland injury
 Neonatal facial nerve injury

132. Causes:
 Systemic:
 DM
 Hypothyroidism
 Uremia
 PAN
 Wegener’s granulomatosis
 Sarcoidosis
 Leprosy
 Leukemia

133. Labs:
 Pure-tune audiometry
 Electrophysiologic tests
 Imaging tests
 Others

134. Labs:
 Electrophysiologic tests:
 Nerve Excitability Test: NET
 Maximum stimulation Test: MST
 Electroneurography: ENoG
 Electromyography: EMG

135. Complications:
 Incomplete recovery
 Exposure keratitis
 Synkinesis
 Tics and spasms
 Contractures
 Crocodile tears
 Frey’s syndrome “gustatory sweating”
 Psychological and social problems

137. Bell’s Palsy
Dr. Saud ALROMAIH

138. Background:
 one of the most common neurologic disorders
affecting the cranial nerves.
 abrupt, unilateral, peripheral facial paresis or
paralysis without a detectable cause.

139. Background:
 first described more than a
century ago by Sir Charles
Bell,
 yet much controversy still
surrounds its etiology and
management.
 Bell palsy is certainly the most
common cause of facial
paralysis worldwide.

140. Incidence:
 United States
 Internationally

141. Incidence:
 The incidence of Bell palsy in the United
States is approximately 23 cases per 100,000
persons.
 Internationally: The incidence is the same as
in the United States.

142. Demographics:
 Race:
 Sex:
 Age:

143. Demographics:
 Race: slightly higher in persons of Japanese
descent.
 Sex: No difference exists
 Age: highest in persons aged 15-45 years.
Bell palsy is less common in those younger
than 15 years and in those older than 60
years.

144. Pathophysiology:
 Main cause of Bell's palsy is latent herpes
viruses (herpes simplex virus type 1 and
herpes zoster virus), which are reactivated
from cranial nerve ganglia.
 Polymerase chain reaction techniques have
isolated herpes virus DNA from the facial
nerve during acute palsy.

145. Pathophysiology:
 Inflammation of the nerve initially results in a
reversible neurapraxia,
 Herpes zoster virus shows more aggressive
biological behaviour than herpes simplex
virus type 1

146. History:
 The most alarming symptom of Bell's palsy is
paresis
 Up to three quarters of affected patients think
they have had a stroke or have an intracranial
tumour.

147. History:
 The palsy is often sudden in onset and
evolves rapidly, with maximal facial weakness
developing within two days.
 Associated symptoms may be hyperacusis,
decreased production of tears, and altered
taste.

148. History:
 Patients may also mention otalgia or aural
fullness and facial or retroauricular pain,
which is typically mild and may precede the
palsy.
 A slow onset progressive palsy with other
cranial nerve deficits or headache raises the
possibility of a neoplasm

149. Physical exam:
 Bell's palsy causes a peripheral lower motor
neurone palsy,
 which manifests as the unilateral impairment
of movement in the facial and platysma
muscles, drooping of the brow and corner of
the mouth, and impaired closure of the eye
and mouth.

150. Physical exam:
 Bell's phenomenon—upward diversion of the
eye on attempted closure of the lid—is seen
when eye closure is incomplete.

151. Physical exam:
 Polyposis or granulations in the ear canal
may suggest cholesteatoma or malignant
otitis externa.
 Vesicles in the conchal bowl, soft palate, or
tongue suggest Ramsay Hunt syndrome

152. Physical exam:
 The examination should exclude masses in
the head and neck.
 A deep lobe parotid tumour may only be
identified clinically by careful examination of
the oropharynx and ipsilateral tonsil to rule
out asymmetry.

153. Investigations:
 Serum testing for rising antibody titres to
herpes virus is not a reliable diagnostic tool
for Bell's palsy.
 Salivary PCR for herpes simplex virus type 1
or herpes zoster virus is more likely to
confirm virus during the replicating phase, but
these tests remain research tools.

154. Investigations:
 MRI has revolutionised the detection of
tumours.

155. Investigations:
 Topognostic tests and electroneurography
may give useful prognostic information but
remain research tools.

156.  Nerve Excitability Test: NET :
 Indication: complete paralysis<3wks
 Interpretation: < or = 3.5 mA threshold:
Prognosis Good
 Limitation: Not useful in the 1st
3 days or during
recovery.

157.  Maximum stimulation Test: MST:
 Indication: complete paralysis<3wks
 Interpretation: Marked weakness or no muscle
contraction: advanced degeneration with
guarded prognosis
 Limitation: Not Objective.

158.  Electroneurography: ENoG :
 Indication: complete paralysis<3wks
 Interpretation: < 90% degeneration: prognosis
is good; > or = 90%: prognosis is question
 Limitation: False-positive results in deblocking
phase.

159.  Electromyography: EMG
 Indication: Acute paralysis less than 1 week or chronic
paralysis longer than 2 weeks
 Interpretation:
 Active mu: intact motor axons
 Mu + fibrillation potentials: partial degeneration
 Polyphasic mu: regenerating nerve
 Limitation: cannot assess degree of degeneration or
prognosis for recovery.

160. Diagnosis:
 Bell palsy is a diagnosis of exclusion.
 Other disease states or conditions that
present with facial palsies are often
misdiagnosed as idiopathic.

161. Management:
 The main aims of treatment in the acute
phase of Bell's palsy are to speed recovery
and to prevent corneal complications.
 Treatment should begin immediately to inhibit
viral replication and the effect on subsequent
pathophysiological processes that affect the
facial nerve.
 Psychological support is also essential, and
for this reason patients may require regular
follow up.

162. Management, Eye care

163. Management, Eye care
 It focuses on protecting the cornea from
drying and abrasion due to problems with lid
closure and the tearing mechanism.
 The patient is educated to report new findings
such as pain, discharge, or change in vision.
 Lubricating drops should be applied hourly
during the day and a simple eye ointment
should be used at night.

164. Management, Steroid

165. Management, Steroid
 Two systematic reviews concluded that Bell's
palsy could be effectively treated with
corticosteroids in the first seven days,
providing up to a further 17% of patients with
a good outcome in addition to the 80% that
spontaneously improve.

166. Management, Steroid
 Usual regimen is 1mg/kg/day for 1 week.
 To be tapered in the 2nd
week.

167. Management, Steroid
Cochrane review*:
“There is insufficient evidence about the effects of
corticosteroids for people with Bell's palsy,
although their anti-inflammatory effect might
prevent nerve damage.”
*Salinas RA, Alvarez G, Ferreira J. Corticosteroids for Bell's palsy
(idiopathic facial paralysis). Cochrane Database of Systematic Reviews
2004, Issue 4. Art. No.: CD001942.

168. Management, Antivirals
 It seems logical in Bell's palsy because of the
probable involvement of herpes viruses.
 Aciclovir, a nucleotide analogue, interferes
with herpes virus DNA polymerase and
inhibits DNA replication.

169. Management, Antivirals
 Usual regimen is 4000mg/24hrs divided into 5
doses for 7 to 10 days

170. Bell’s palsy:
Antivirals:
Cochrane review*:
“More evidence is needed to show whether the
antiviral drugs acyclovir or valacyclovir are
effective in aiding recovery from Bell's palsy.”
* Allen D, Dunn L. Acyclovir or valaciclovir for Bell's palsy (idiopathic facial
paralysis). Cochrane Database of Systematic Reviews 2004, Issue 3.
Art. No.: CD001869.

171. Outcomes:
 It has a fair prognosis without treatment, with
almost three quarters of patients recovering
normal mimetical function and just over a
tenth having minor sequelae.
 A sixth of patients are left with either
moderate to severe weakness, contracture,
hemifacial spasm, or synkinesis.

172. Outcomes:
 Patients with a partial palsy fair better, with
94% making a full recovery.
 The outcome is worse when herpes zoster
virus infection is involved in partial palsy.

173. Outcomes:
 In patients who recover without treatment,
major improvement occurs within three weeks
in most.
 If recovery does not occur within this time,
then it is unlikely to be seen until four to six
months, when nerve regrowth and
reinnervation have occurred.

174. Bad Prognostic Factor:
 Complete facial palsy
 No recovery by three weeks
 Age over 60 years
 Severe pain
 Ramsay Hunt syndrome (herpes zoster virus)
 Associated conditions—hypertension,
diabetes, pregnancy
 Severe degeneration of the facial nerve
shown by electrophysiological testing

175. ?

176. Thanks

177. MUSCLE ACTION
Risorius Smile
Buccinator Aids chewing by holding
cheeks flat
Levator Labii Superioris Elevates upper lip
Levator labii superioris
alaeque nasi
Snarl
Levator Anguli Oris Soft smile
Nasalis Flare Nostrils
Orbicularis oris muscle Purse Lips
Depressor Septi Nasi Depresses Nasal Septum
Procerus Moves Skin of Forehead
The buccal branch supplies these muscles