Anatomy & Disorders

By Dr. Jennifer Lee P.H.

INTRODUCTION

Seventh cranial nerve Essentially a motor nerve Nerve of the 2nd branchial arch

EMBROLOGY
Main

pattern, branching pattern and relationships established during 1st 3 months of intrauterine life not fully developed until 4 years after birth

Nerve

 Facial

nerve develops within the 2nd pharyngeal arch associated with middle and external ear arouses suspicion of anomalies of the facial nerve within the temporal bone misplaced and exposed facial nerve eg. Herniation of the nerve into the middle ear cavity

Abnormalities

FUNCTIONAL COMPONENTS
1.Special visceral (branchial) efferent
to muscles responsible for facial

expression & for elevation of hyoid bone

2. General visceral efferent (parasympathetic) are secretomotor to

Submandibular

and sublingual

salivary glands Lacrimal gland Mucous glands of the nose, palate & pharynx

3. Special visceral afferent fibres carry taste sensations from the anterior 2/3rds of the tongue and palate

4. General somatic afferent fibres innervate a part of the skin to the ear through some branches with the Vagus N. Proprioceptive impulses from muscles of face reach through the Trigeminal Nerve.

Fibres of the nerve arise from 4 NUCLEI situated in the lower pons
nucleus brachiomotor Superior salivary nucleus
Motor

parasympathetic
Lacrimatory

nucleus parasympathetic

Nucleus

of the tractus solitarius -

gustatory

MOTOR NUCLEUS lies deep in the reticular formation of the lower pons. The part of the nucleus that supplies muscles of the upper part of the face receives corticonuclear fibres from the motor cortex of both the Rt. & Lt. Sides.

In contrast, the part of the nucleus that supplies muscles of the lower part of the face receive corticonuclear fibres only from the opposite cerebral hemisphere

Motor root of CNVII

Motor nucleus of CNVII Superior salivary nucleus Tractus solitarious Nervus intermedius

Int aud meatus Geniculate ganglion

Nerve to stapedius

Lacrimal gland
Sphenopalatine ganglion

Greater s.f. petrosal nerve Sublingual gland

Submandibular gland

Chorda tympani
Stylomastoid foramen

Terminal branches

SEGMENTS-COURSE-LENGTH

MEATAL : (23-24mm) brain stem to

Internal Auditory Meatus(IAM)

LABYRINTHINE : (3-5mm) meatal

foramen to geniculate ganglion

TYMPANIC : (8-11mm) geniculate

ganglion to pyramidal eminence

 MASTOID

: (10-14mm) pyramidal process to stylomastoid foramen

: (15-20mm) stylomastoid foramen to muscles of facial expression, posterior belly of digastric, stylohyoid & postauricular

EXTRATEMPORAL

COURSE & RELATIONS

Attached

to the brainstem by 2 roots, i.e. the motor & sensory (nervus intermedius or nerve of Wrisberg)

Attached

to the lateral part of the lower border of the pons just medial to the 8th CN. laterally & forwards with the 8th CN to reach the internal acoustic meatus.

Runs

In the Internal Auditory Meatus, the motor root lies in a groove on the 8th CN, with the sensory nerve intervening. They are accompanied by the labyrinthine vessels

Facial & some connections-dissection of rt. Middle cranial fossa

IAM IAC IAM

brainstem

Anatomical relationships of the facial, acoustic and vestibular nerves(CNVIII)-from Lt. postauricular approach

At the fundus of the meatus, the 2 roots fuse to form a single trunk which lies in the petrous temporal bone.

Motor root of CNVII

Motor nucleus of CNVII Superior salivary nucleus Tractus solitarious Nervus intermedius

Int aud meatus Geniculate ganglion

Nerve to stapedius

Lacrimal gland
Sphenopalatine ganglion

Greater s.f. petrosal nerve Sublingual gland

Submandibular gland

Chorda tympani
Stylomastoid foramen

Terminal branches

The nerve is divided into 3 parts by 2 bends. 1st part is directed laterally above the vestibule. 2nd part runs backward above the promontory at the medial wall of the middle ear.

3rd part runs vertically downwards behind the promontory.

Lspn

Gspn

genu

facial nerve

1. 2. 3. 4. 5. 6.

7. 8.

a) Temporal bone, petrosal portion. b) Temporal bone, mastoid portion. c) Promontorium. d) Oval window. e) Round window. f) Auditory tube (Eustachian tube). g) m. Tensor tympani. h) m. Stapedius. i) Internal carotid artery. k) Internal jugular vein. facial nerve. genu of facial nerve. greater superficial petrosal nerve. lesser superficial petrosal nerve. glossopharyngeal nerve. tympanic nerve (s. Jacobsonii) with branches to the round and oval windows, to the tubes, and to the internal carotid plexus. lesser deep petrosal nerve. vagus nerve with auricular ramus.

The facial nerve leaves the skull by passing through the stylomastoid foramen. It crosses the lateral side of the base of the styloid process. It enters the posteromedial surface of the parotid gland & divides into 5 terminal branches

BRANCHES
WITHIN

THE FACIAL CANAL

Greater

petrosal nerve - carries gustatory & parasympathetic fibres. Arising from the geniculate ganglion. joins the deep petrosal nerve to form the nerve to the pterygoid canal.

Nerve to the stapedius damps excessive vibration of stapes by high pitched sounds Chorda tympani 6mm from SMF leaves the facial n. & emerges from petrotympanic fissure. It joins lingual n. in the infratemporal fossa 2cm below BOS. Carries preganglionic secretomotor fibres to submandibular & sublingual salivary glands, & taste fibres from anterior 2/3rds of the tongue.

Tympanic and vertical segments of the facial nerve view of middle ear

 AT

THE STYLOMASTOID FORAMEN

Posterior

auricular- supplies auricularis post., occipitalis, intrinsic m. at back of auricle Digastric post. belly of digastric m. Stylohyoid stylohyoid muscle

 COMMUNICATING

BRANCHES WITH ADJACENT CRANIAL & SPINAL NERVES

For

effective coordination between the movements of the muscles of 1st, 2nd, 3rd branchial arches Also communicates with sensory nerves distributed over its motor territory

 TERMINAL

BRANCHES

Temporal

auricularis ant. & sup.,frontalis,int. m. at lat. Side of ear, orbicularis oculi,corrugator supercilii
orbicularis oculi

Zygomatic

 Buccal

upper & lower branch

Mandibular

runs deep to platysma.muscles of lower lip & chin

supplies platysma

Cervical

BLOOD SUPPLY
1. Ant. Inf. Cerebellar a. supply the meatal segment within the int. aud. canal. 2. Petrosal branch of mid. meningeal a. supplies the nerve in the perigeniculate ganglion. 3. Stylomastoid branch of the postauricular a. feeds the mastoid & tympanic segments.

Facial nerve identified by several anatomical landmarks (extracranial) :

Tragal pointer lies 1cm medial & deep Bisection of the angle between digastric muscle and the mastoid bone Bisection of the angle between the mastoid process and vaginal process of the tympanic bone

PATHOPHYSIOLOGY OF NERVE INJURY

physiological block with no anatomical disruption. Temporary. AXONOTMESIS Axon sheath is intact but axon is divided with distal degeneration of the nerve fibres. NEURONOTMESIS Whole nerve is severed with distal degeneration of the nerve. Neuroma may form.
NEUROPRAXIA

FACIAL NERVE PALSY

SUPRANUCLEAR

palsy occurs on opposite side of lesion

INFRANUCLEAR-

palsy occurs on same side of lesion & upper part of face is involved. Flaccid type of paralysis.

SUPRANUCLEAR

INFRANUCLEAR

SUPRANUCLEAR FACIAL NERVE PALSY

Cortex

& Internal capsule lesions, paresis UL with MCA, paresis LL with ACA lesion of basal ganglia, parkinsonism, Meiges syndrome

Extrapyramidal

Midbrain

unilateral Webers

syndrome

Pontine

nucleus pontine glioma, MS, polio, encephalitis, MillardGubler syndrome, Fovilles syndrome, Moebius syndrome

INFRANUCLEAR FACIAL NERVE PALSY

CAUSES :
A.

INTRACRANIAL BRAIN STEM

1.

Vascular thrombosis,embolism, hemorrhage of vertebro-basilar artery

SUPRANUCLEAR OR INFRANUCLEAR

2.

Trauma to brain stem because of head injury Infections polio, diphteria, infective polyneuritis

3.

4.

CP angle lesions Acoustic neuroma,

meningioma, glomus jugulare tumor, cholesteatoma

5.

Disseminated sclerosis

Between the brain stem & the Internal auditory meatus (BOS)
1. Trauma fracture of the BOS - excision of acoustic neuroma - surgery of trigeminal ganglion 2. Meningitis non-specific, TB, - syphilitic

3. Tumours Acoustic neuroma, meningioma, glomus jugulare tumor

4. Others osteopetrosis, leukaemia, Landry-Guillain-Barre, malignant otitis externa

PALSY ON WHICH SIDE?

B. INTRATEMPORAL(90% CASES)

IDIOPATHIC : Bells palsy TRAUMA Head injuries with fracture of temporal bones esp. transverse fractures, contusional injuries

1.

2.

Postoperative mastoidectomy, stapedectomy

3.

Penetrating injuries of middle ear

 INFECTIONS
1. Complications of acute & chronic otitis media 2. Ramsay-Hunt Syndrome characterised by herpetic eruptions in the ext. aud. Canal caused by Herpes Zoster.

VESICLES OVER PINNA

 TUMOURS - Acoustic Neuroma, benign & malignant tumours.

C. EXTRACRANIAL Trauma- birth trauma, forceps delivery - Facial injuries - Post-operative low post-aural incision in children - after parotidectomy

 metastatic lymph nodes in the upper part of post. triangle - parotid tumours, NPC D. GENERAL DIABETES LEAD POISONING CONGENITAL Moebius Syndrome, - Landry-Guillan-Barre INFECTIONS Poliomyelitis, diphtheria, syphilis, sarcoidosis
TUMOURS

BELLS PALSY
Most

common type of idiopathic lower motor neuron facial nerve palsy (50%). Incidence of 15-40 per 100,000 people Most prevalent in 3rd decade of life. Diagnosis of clinical exclusion.

 Sudden,

complete, self limiting, nonprogressive, non life-threatening, spontaneously remitting, neither preventable nor cured Probably a viral neuropathy- Herpes Simplex Virus reactivation in the geniculate ganglion Sudden paralysis or paresis of all facial muscle groups on one side of face.

Characterised

by viral prodrome(60%), periauricular pain(50%), facial numbness(40%), changes in taste(50%), numbness of tongue(20%) May & Hardin, 1977 Diminished taste, difficulty chewing, hyperacusis, hypesthesia in one or more branches of the CN V.

Viral

prodromal of 3-5 days duration of symptoms at 48 hours.

Peak

90%

recovery if paralysis is incomplete over several days.

Palsy is NOT Bells if one of the following is present

Signs

of tumor simultaneous palsy

Bilateral

Vesicles
Involvement

nerves

of other motor cranial

 History Ear

& findings of trauma

infection of CNS lesion palsy at birth

Signs Facial

Triad

of IM (fever, sorethroat, cervical LN)

COMPLICATIONS
EXPOSURE

KERATITIS diminished tearing, inability to close the eyelid completely, loss of corneal sensitivity

INVESTIGATIONS
TESTING

ALL MUSCLE GROUPS AUDIOGRAM To exclude any inner or middle ear hearing abnormality CHEST X-RAY - ? Sarcoidosis

SCHIRMERS

TEST to assess parasympathetic innervation to the lacrimal gland via the greater s.f. petrosal nerve. MRI CP angle & int. aud. Canal CT Scan traumatic causes

 NERVE

EXCITABILITY TEST (NET) A 1/sec2 wave pulse applied over the affected & unaffected facial nerves. Thresholds for minimal muscle response are compared. A 3-4mA or more difference is significant, suggesting denervation. Not accurate in first 72 hours after onset of paralysis.

 MAXIMAL

STIMULATION TEST (MST) difference in facial muscle movement between the normal & involved sides after stimulation

 ELECTRONEURONOGRAPHY

(ENoG) to predict which patients may benefit from surgical decompression. Must be performed within 2 weeks of onset of symptoms.

 ELECTROMYOGRAPHY

(EMG) determines activity of the muscle. Provides information regarding intact motor units in the acute phase, to confirm the integrity of intact axons in the recovery phase

TREATMENT
1.

MEDICAL

Antimicrobial

or antiviral Oral steroids 7-10 day course within the first 48 hours after onset

 Prophylactic

eye care against exposure

keratitis Bells palsy prednisolone 1mg/kg/day for 10 days, tapering over 4-7 days, with acyclovir 800mg 5 times/day or valacyclovir 500mg 2 times/day and eye care.

2. SURGICAL
CLINICAL SCENARIO SURGICAL INTERVENTION NERVE DECOMPRESSION,ANASTOM OSIS MYRINGOTOMY DECOMPRESSION, MASTOIDECTOMY DECOMPRESSION, ANASTOMOSIS DECOMPRESSION

TRAUMA

ACUTE OM CHRONIC OM IATROGENIC INJURY COMPLETE IDIOPATHIC PARALYSIS

Melkersson-Rosenthal Syndrome

1. 2. 3. 4. 5. 6.

Most common rare disorder Characterised by : Recurrent alternating facial palsy Recurrent edema of lips, face, eyelids Cheilitis Fissured tongue May have migraine Positive family history

Bilateral simultaneous palsy

May

be medical emergency Most common cause is GB syndrome Other causes : Bells palsy, leukaemia, bulbar palsy, GB syndrome, acute leukaemia & bulbar palsy post rabies immunisation are life threatening medical emergencies.

Guillain-Barr Syndrome
Acute

inflammatory polyradiculoneuropathy evolving as a paralytic disease of unknown origin Lymphocytic cellular infiltration of peripheral nerves with myelin destruction Paresis or paralysis usually starts in LL Tendon reflexes absent in affected limbs Facial diplegia seen in half of cases

HOUSE BRACKMANN CLASSIFICATION-results from recovery from facial paralysis after 1 year GRADE I II III DEFINITION
Normal symmetrical function Slight weakness noticeable. Complete eye closure with min effort Obvious weakness. Complete eye closure with max effort

IV
V VI

Obvious disfiguring weakness. Incomplete eye closure with max effort Inability to lift eyebrow Motion barely perceptable. Similar to Gd IV + slight movement corner mouth No movements

PALSY ON WHICH SIDE?

Bell's phenomenon

Bell's phenomenon is a medical sign in patients with peripheral facial paralysis that is characterized by the failure of the eyelid on the paralysed side to close, along with an upward movement of the eye on the same side, when an attempt is made to close the eyes. The phenomenon is named after the Scottish anatomist, surgeon, and physiologist Charles Bell.

Facial paralysis
In

most cases, the cause of facial paralysis can be determined on the basis of the clinical evaluation, & expensive diagnostic tests can be avoided. Because Bells palsy is not always the cause, physicians need to be able to identify critical finding on history & physical examination that indicate an alternative diagnosis.once identified, this finding can lead to a specific & directed evaluation. Marenda SA,Otolaryngol Clin North Am 30:669-682,1997

THE END