Evaluation and Management of Facial Nerve Palsy by Dr.Aditya Tiwari.

1. 07/10/2014
By
Dr. Aditya Tiwari,
Resident, Dept. of ENT, JNMC.

2. “The human face is the organic seat of
beauty. It is the register of value in
development, a record of Experience,
whose legitimate office is to perfect the life,
a legible language to those who will study it,
of the majestic mistress, the soul."
- Farnham, Eliza
QUOTE

3.  Introduction
 Causes
 Evaluation of nerve function.
 Goals of management of FN palsy
 Factors governing T/t of FN palsy
 Assessment & planning
 Management of facial nerve palsy
 FN disorders in newborn &children

4.  Facial function plays an integral part in
our everyday lives
- Smile; nonverbal communication, etc.
 Facial paralysis is devastating on many
leveL
Functional
Cosmetic
 Fortunately, a plethora of techniques are
available to treat the paralyzed face.

8. In middle ear surgery, the most comman site of inury is the
tympanic segment due to high incidence of fallopian canal
dehiscence in that region. During mastoid surgery, the facial
nerve is most commanly inured at the secong genu
Skull base neoplasms & metastasis from breast and lung cancer
are comman neoplasms causing facial paralysis in adults.
Leukemia, lymphoma are the most comman etiologies in
children.
A facial palsy progressive beyond 3 weeks since onset & with no
returns of function by 6 months is considered to be caused by
tumor until proven by otherwise
If greater than 90% neural degeneration occurs with in 2 weeks,
the mastoid & tympanic segment are decompressed.

9.  HISTORY is of vital importance to establish
the onset characteristics, duration and
degree of recovery.
 Previous trauma, surgery or infection may
help in arriving at a diagnosis
 Examination of the face at rest and
movement.
 Radiolologic evaluations
 Topodiagnostic & Nerve excitability tests.

10.  Normal appearnce at rest
 Symmetry at involuntry motion.
 Restoration of oral, ocular & nasal
sphincter
 No loss of other significant functions.

11.  Age
 Medical history.
 Residual hearing.
 Prior h/o ear discharge.
 Segment of nerve injured.
 Patient’s expectations.
 Risk tolerance.

12.  Cause of facial paralysis
 Functional deficit/extent of paralysis
 Time course/duration of paralysis
 Likelihood of recovery
 Other cranial nerve deficits
 Patient’s life expectancy
 Patient’s needs/expectations

14.  Psychological Trauma :- The most
significant complication is the social
isolation & these patients often succumb
to.
 Depression :- Patient often become by
the facial deformity.
 The patient must be
encouraged to to adopt
positive outlook.

15.  Group therapy has been effective in
helping patients to deal with facial
deformity.
 Resultls are better when group members
are selected of the same age group &
same age.
 Patient should be learned to adapt
permenant deformity in a positive way.

16.  MEDICAL TREATMENT : -
a) Physical therapy
b) Pharmacological therapy
c) Psychophysical therapy
 Surgical treatment : -
a) Nerve decompression - Internally or
externally.
b) Nerve anastomosis
c) Nerve grafting
 Physiotherapy

17.  It includes application of heat, massage
& exercises performed twice a day.
 Patient is adviced to follow these steps –
a) Wet cotton towel with hot water,
wring it out, keep the hot towel on the
face until the towel cools.
b) Massage facial cream on skin
around the eyes & mouth and mid face for
few minutes.
c) Stand infront of mirror Watch face
while doing facing exercises Intact nerve
fibres activated & muscle tone maintained

18.  In case of the Bell’s palsy :-
a) Oral antivirals - Acyclovir is DOC.
b) Corticosteroids
c) Eye protection
d) Follow progression with serial exams
e) Physiotherapy.
 Prednisolon is steroidal drug of choice in
both Bell’s palsy & Ramsay Hunt
syndrom.

19.  If the patient is seen within 2 to 3 weeks
of onset of symptoms-tab. Prednisolone
in doses of 1mg/kg/d for 10 to 14 days
has been recommended with a gradual
tapering.
 Vitamins B1, B6, B12 may be
administered which helps in nerve
conduction & regeneration.
 If patient is seen after 3-4 weeks, then
steroid therapy is of no use.
 Non-narcotic analgesic is used to control
pain in Bell’s Palsy & mainly Ramsay Hunt
syndrom.

20. Medical management of Bell’s

21.  Nerve decompression - Internally or
externally
 Nerve anastomosis
 Nerve grafting
Due to “skip” regions & diffuse neuritis of the facial
nerve, surgical decompression is not recommended in
Ramsay Hunt syndrome.

22.  A. Acute (< 3 wks)
1) Nerve
exploration/decompression
2) Nerve repair
a) Primary anastomosis
b) Cable grafting
i) Great auricular nerve
ii) Sural nerve
 B. Intermediate (3 wks- 2
yrs)
1) Nerve transfer
a. Hypoglossal-facial
b. Spinal accessory-facial
c. Masseteric-facial
2) Cross face nerve grafting
using sural nerve
 C. Chronic (>2 yrs)
1) Muscle transfers
a. Temporalis
b. Masseter
c. Digastrics
2) Free muscle flaps/
microneurovascular transfer
a. Gracilis
b. Latissimus dorsi
c. Serratus anterior
d. Pectoralis minor
 D. Static
procedures/ancillary
procedures (can be
performed at any time period
listed above)
1) Gold weight/spring
implants
2) Slings
3) Lid procedures

23.  Timing : within 72 hrs
 Indication :
a) < 10% or less muscle function on ENoG,
b) with absent voluntary muscle action
potential on EMG
 Method :
a) Done by removing the facial fallopian
canal all around with widening of the
canal with diamond burrs.
b) Perineural and epineural sheaths are
split open (to drain perineural or
intraneural edema / haematoma)

24.  Transmastoid/Retrosigmoid
approach
 Middle cranial fossa approach.
 Retrolabyrinthine approach.
 Translabyrinthine approach.

25. Indication :-
 Tumors limited to the tympanic and/or the
mastoid segment of the facial nerve regrdless
of preoperative hearing loss
 Longitudinal fractures of temporal bone (only
mastoid segmental involvement)
 AOM, COM involving only tympanic segment
and genu
 Isolated mastoid fracture
 Infections involving the mastoid segment
Limitations :-
 Limited access to geniculate ganglion
 No access to labrynthine segment

26. Procedure:-
a) Mastoidectomy air cells removed from
antrum downward to mastoid tip & ridge
of the diagastric groove is defined cells
also removed from the antrum forward to
the root zygoma, until the upper edge of
the incus & prominance of bony horizantal
canal identified.
b) Landmark for the vertical mastoid portion
of FN is post tip of incus above & ant end
of diagastric groove below drilled upto
stylomastoid foramen bone between
foramen & horizantal SSC thinned & FN
nerve is approached as pink streak.

27. DECOMPRESSION:-
a) When horizantal segment of FN involved,
decompression done via triangle
bounded by FN med., chorda tympani
nerve & tympanic annulus laterally &
short process of incus sup.
b) When patient’s hearing is normal & entire
horizantal seg. of FN must be
decompressed, incus must also be
disarticulated.
c) Disposable Beaver knife is used for the
decompression of the FN by slitting the
nerve sheath.

29.  Exposure from IAC to Tympanic segment
(for intracanalicular and labrynthine
segments)
 INDICATIONS :-
a) Bells palsy,
b) Longitudinal temporal bone fractures
 Advantages :-
a) No hearing impairment, even
geniculate ganglion and tympanic
segment can be decompressed, when
b) Combined with retrolabyrinthine,
transmastoid entire facial nerve can be
seen.

30. PROCEDURE :
 6x8cm trap door incision above ear (with postaural incision)
 4x4 cm temporalis fascia graft harvested
 Anterior based temporalis musculo perisosteal flap elevated
 A bone flap centered over zygoma elevated, taking care
middle meningeal artery on inner table
 Dura elevated from posterior to anterior till petrous ridge,
arcuate eminence, meatal plane, and GSPN Anteriorly.
 Blue lining of superior semicircular canal seen
 Anterior to it IAC opened with 7th nerve anterosuperiorly (BILLS
BAR FORMS LATERAL BOUNDARY OF MEATAL FORAMEN)
 Labrynthine segment followed laterally till geniculate ganglion.
 Tegmen tympani removed
 Tympanic segment blue lined and final layer of bone removed
with elevator and decompressed
 Bone flap replaced, with temporalis fascia over it to seal the
defect.

31. Complications :-
 CSF leak, CHL/SNHL, meningitis,
 Bleeding from AICA, brainstem and
cerebellar infarction
 Injury to AICA

32.  For exposure from brainstem to IAC
 ADVANTAGES :-
a) Access without inner ear sacrifice
b) Minimal cerebellar compression as compared
to suboccipital approach.
 Disadvantages :-
a) 8th nerve hampers 7th visualisation and can
lead to hearing loss
b) Reduced intracranial exposure so intracranial
vascular complications very diff to manage
 Complications :-
CSF leak, Hearing impairment, cerebellar
compression, vascular intracranial
complications

33.  Indications :
7th and 8th nerve function already lost
 Advantages :
a) Entire nerve is exposed using single
approach
b) If interposition graft is required, enough
working space is available even at the
level of brainstem
 Limitations :
Hearing and balance function loss,
CSF leak, Infections

34.  Facial nerve repair is the most effective
procedure to restore facial function in
patients who have suffered nerve
damage from an accident or during
surgery.
 It involves
microscopic repair
of a nerve that has
been cut

35.  End-to-end
anastomosis preferred
Adv - No tension
 Extratemporal repair
performed < 72 hrs of
injury
 Most common method
a) Group fascicular
repair
b) Epineural repair
Group fascicular
repair

36.  Severed ends of nerve
exposed
 Devitalized tissue/debris
removed with fine
scalpel
 Small bites of epineurium
 Epineural sheath
approximated with 9-0
nonabsorbable suture
 Epineural repair
recommended for injury
proximal to pes anserinus
and intratemporal EPINEURAL REPAIR TECHNIQUE

37.  Cable grafts
Used when defect > 17mm nerve
cannot be re-approximated without
tension
 Most common nerves used are:-
a) Greater Auricular Nerve
b) Sural Nerve
c)Medial & lateral antibrachial
cutaneous nerves
c) Sensory nerves from superficial
cervical plexus
Motor nerve grafts are better than sensory nerve

38. Harvesting :-
 Located on lateral surface
of SCM at the midpoint of a
line drawn between
mastoid tip and mandibular
angle.
 May extend postauricular
incision or use separate
neck incision.
 Ideally used for graft upto
10 cm in length.

39.  Advantages:
a) Proximity to facial nerve
b) Cross-sectional area
c) Limited morbidity
 Limitations:
a) Reconstruction of long defects
b) Ideal for defects < 6cm in length
Recently, the idea of nerve repair using
autogenous axially aligned freez-
thrawed skeletal muscle has been
proposed.

40.  Anatomy:-
Formed by union of medial
sural cutaneous nerve and
lateral sural cutaneous
branch of peroneal nerve
 Advantages :-
 Diameter equal to FN dia.
 Length : >10cm
 Accessibility
Low morbidity associated
with sacrifice
 Disadvantages:
Variable caliber
 Often too large
 Difficult to make graft
approximation
Unsightly scar

41.  Donor nerves are XII CN, spinal accessory,
masseteric branch of trigeminal nerve.
 Restores movement to the side of the face
that has been paralyzed.
 With the stump of the 12th nerve hooked up
to the end of the 7th nerve, the face will
move when the tongue is moved.
Best outcomes from cross facial nerve grafting
obtained if the period of denervation is less than 6
months.

42.  INDICATIONS:
 Irreversible facial nerve injury
 Intact facial musculature/distal facial nerve
 Intact proximal donor nerve
 Prior to distal muscle/facial nerve atrophy
 Ideal if performed within a year of facial paralysis
 Advantages:-
 Time interval until movement
4-6 months
 Avoid multiple sites of anastomosis
 Mimetic-like function achievable
with practice
Disadvantages:-
 Donor site morbidity
 Some degree of
synkinesis

43. 1) Parotidectomy incision
extended into cervical
crease ~ 2-3 cm below
inferior border of mandible
2) Facial nerve identified and
dissected distal to pes
anserinus
3) Identify hypoglossal nerve
a) SCM retracted posteriorly
b) Dissect superiorly until
posterior belly of digastic is
identified
c) Retract digastric
superiorly and CN XII is
found inferiorly.
d) Hypoglossal is within 2-3
cm of main trunk of the
facial nerve
1) Hypoglossal nerve is dissected
anteriorly and medially into the
tongueTransect distal to ansa
hypoglossis
2) Facial nerve transected at the
stylomastoid foramen

44. Entire hypoglossal nerve
transected
40% segment of
nerve secured to
lower division
Hypoglossal
nerve
reflected
superiorly
“Split” XII – VII cranial nerve transfer
transfer

45.  End to end
neurorrhaphy between
XII CN & donor cable
nerve graft ( eg.
greater auricular nerve)
which serves as a jump
graft to the main trunk
of facial nerve
Jump graft modification

46.  Facial nerve can be
mobilised in its
mastoid segment
from 2nd genu distally
& rotated inferiorly to
allow direct
coaptation to the
hypoglossal nerve.
 It typically requires
removal of the
mastoid tip.
Reflection of the facial
nerve out of the mastoid
bone.

47.  Contralateral Facial nerve used to
reinnervate paralyzed side using a nerve
graft
 Sural nerve often employed
~25-30cm of graft needed
 Restitution of smile and eye blinking
obtained.
 Disadvantage:-
a)2nd surgical site
b)Violation of the normal facial nerve

48. FOUR techniques
 Sural nerve graft routed from
buccal branch of normal VII
to stump of paralyzed VII
 Zygomaticus and buccal
branch of normal VII used to
reinnervate zygomatic and
marginal mandibular portions
respectively
 4 separate grafts from
temporal, zygomatic, buccal
and marginal mandibular
divisions of normal CN VII to
corresponding divisions on
paralyzed side.
 Entire lower division of normal
side grafted to main trunk on
paralyzed side.

49. INDICATION:
 Congenital facial paralysis
 Facial nerve interruption of at least 3
years
 Loss of motor endplates
 Crossover techniques not possible due to
donor nerve sacrifice

50.  Often used for
reanimation of the oral
commisure.
 Middle 1/3 of muscle is
best for transfer (Sherris,
2004)

51.  Incision in preauricular
crease extending to sup.
temporal line
 Obtain wide exposure of
temporalis muscle by
dissecting above the
SMAS
 Incise down on
periosteum to elevate
muscle fibers
 Harvest middle 1/3
 Large tunnel created
over zygomatic arch
 Orbicularis oris muscle
exposed via vermilion
border incision at oral
commissure

52.  Large tunnel over zygomatic arch used
to connect oral commisure to zygomatic
arch/superior incision.
 Temporalis flap detached and elevated
from its origin and tunneled to the oral
commissure.
 3-0 prolene used to suture orbicularis to
temporalis at oral commissure
 Overcorrection of nasolabial fold and
oral commissure

53.  Used when temporalis muscle is not
opted.
 May be preferred due to avoidance of
large facial incision
 Disadvantages:-
a) Less available muscle compared to
temporalis
b) Vector of pull on oral commisure is
more horizontal than
superior/oblique like temporalis

54.  Vertical incision made in inferior portion
of muscle.
 Anterior half of muscle is split into 2
divisions.
 The 2 anterior slips of muscle are
tunneled anteriorly to reach the oral
commisure via external vermillion border
incisions.
 Muscle slips are attached to lips and oral
commisure in the deep dermal layer
using suture.

55.  They have potential of achieving individual
segmental contractions
› Reduction of synkinesis
 Muscle flaps used are:
› Gracilis
› Latissimus dorsi
› Inferior rectus abdominus

56.  Requires viable muscle and nerve
innervation
 Traditionally done in 2 stages
a) 1st:- Cross-face nerve graft ~ 1 yr prior
to muscle transfer.
b) 2nd:- Muscle transfer performed after
neural ingrowth of graft.

57. 1. “Workhorse” for free
muscle transfer
2. Long, thin muscle in
medial thigh
-Good neurovasular
pedicle
1. Adductor artery
and vein
2. Anterior obturator
nerve
3. 2 stages involved:
1. Sural nerve employed
for cross-face graft
2. Gracilis muscle
transferred after 6-12
months
4. Vascular anastomosis to
the facial artery and vein
or to superficial temporal
Anterior Obturator nerve
Adductor a. & v.

58.  Exposure keratitis Corneal ulceration
Corneal breakdown Blindness
 Goal of treatment is to maintain Cornea
safe.
 Complications of orbicularis oculi paresis-
a) Delayed blinking
b) Impairment of nasolacrimal system
c) Dry eye
d) Risk of cornea.

59.  Initial treatment
a) Ophthalmic drops/ointments
b) Protective taping,
c) Occlusive moisture chambers,
d) Soft contact lenses, scleral shields
e) Tarsorrhaphy suture
 Majority of patients require definitive
surgical treatment to correct chronic
impairment

60.  Surgical options include:
a) Palpebral springs (Levine, May)
b) Tarsorrhaphy (McLaughlin)
c) Lid loading & shortening tech(Gold
weight, spring implant)
d) Combinations
e) Temporalis muscle transfer (Gillies)
f) Encircling the upper and lower eyelids
with silicone or fascia lata (Freeman)
Surgical T/t considered when medical T/t fails & in case of BAD
syndrome (Scott-Brown’s 6th edition)
B Bell’s phenomenon
A corneal Anaesthesia
D Dry eye

61.  Advantages
a) Less visible
 Disadvantages
a) Technically difficult
b) Higher risk
of extrusion

62.  Horizontal mattress 5-0 nylon
 Begin 3mm medial to lateral
canthus, 6mm from lid
margin
 Stitch travels through gray
line to 5mm below lower lid
margin
 Bolster with 3mm, 4-french
rubber catheter.
 Cosmetically unappealing,
visual field affected

63.  Early technique
– Incision in the supratarsal crease
– Subcutaneous pocket
– Insert weight
– Close skin
Stainless steel Gold
– High profile
– Migratory
– High rate of extrusion
– Higher density - more weight
in same size
-Malleable - conforms to the
globe-lower profile
– Lower reactivity,
Reversible,Migratory
– High rate of extrusion

64.  Small incision made
several millimeters
above the upper
eyelid margin.
 Tarsal plate exposed
with sharp dissection
 Gold weight secured
to tarsus beneath
levator aponeurosis
using 8-0 nylon.
 Wound closed in 2
layers

65.  Advantages
a) Technically straightforward
b) Consistent
 Disadvantages
a) less than with previous technique
b) Less Visibility
c) Less Extrusion
d) Less Mobility

66. a) Procedure:-
Wedge excision
lateral canthopexy
b)Used in combination
With gold weight
implantation

67.  The two main d/d possibilities are
developmental & traumatic.
 The most common finding asso with
congenital facial palsy is presence of two
or more other anomalies.
Develop. b/l facial palsy is freq. incomplete
with lower portion of face less affected than
the upper part. This distinguishes it from
facial palsy due to trauma, which is rarely
B/L & equally involves upper and lower part
of the face.

68.  At present, with the exception of free
muscle neurovascular transplantation,
there is no effective way to restore facial
function in conginital facial paralysis.
 Delay reanimation surgical procedures
until patient reaches adolescent years.
 Management directed towards
preventing complications.
Main area of concern for reanimation
is the eye.