GOOD MORNING

FACIAL PALSY

COMPILED BY: Dr.Nuzhat Noor Ayesha

PG student (OMFS)
KCDS- B’lore
QUOTE

• "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
 CONTENTS
Introduction
Nerve anatomy & injuries
Facial nerve anatomy
Facial paralysis
Etiology
Bell’s Palsy
Surgical treatment
References
 INTRODUCTION
• Facial function plays an integral part in our
everyday lives
– Smile; nonverbal communication, etc.
• Facial paralysis is devastating on many levels
– Functional
– Cosmetic
• Fortunately, a plethora of techniques are
available to treat the paralyzed face.
 NERVE FIBER COMPONENTS

• Endoneurium
– Surrounds each axon
– Adherent to Schwann cell
layer
– Vital for regeneration
• Perineurium
– Encases endoneural tubules
– Tensile strength
– Barrier to infection
• Epineurium (nerve sheath)
– Outermost layer
– Houses vasa nervosum for
nutrition
 NERVE INJURY

• Two acceptable classification schemes used

to describe the histologic changes that occur
following nerve injury.
 SEDDON CLASSIFICATION (1943)

• Neurapraxia-a conduction block from

transient anoxia owing to acute
epineurial/endoneurial vascular interruption
resulting from mild nerve manipulation with
rapid and complete recovery of sensation.

• Axonotmesis- This damage extends through

and includes the endoneurium with no
significant axonal disorganization.
Recovery is slow and may take weeks to
months, and it may not be complete.

• Neurotmesis- injuries result from complete

or near complete transection of the nerve
with epineurial discontinuity and likely
neuroma formation. Spontaneous
neurosensory recovery is unlikely.
SUNDERLAND CLASSIFICATION (1951)
NEURAL
HEALING
FACIAL NERVE
 FACIAL NERVE
 7th Cranial nerve
 Nerve of the 2nd branchial
arch
 Has two roots. A large
motor and a smaller mixed
sensory and
parasympathetic (nervus
intermedius)
 FUNCTIONAL COMPONENTS
• Brancial motor(special visceral efferent)-
Supplies; Stapedius , Stylohyoid,
posterior belly of digastric muscle and the
muscles of facial expression.

• Visceral motor(general visceral efferent)

Parasympathetic innervations of the
lacrimal, submandibular, and sublingual
glands, as well as mucous membranes of
nasopharynx, hard and soft palate.

•Special sensory(special afferent)-Taste sensation from the anterior 2/3 of tongue;

hard and soft palates.

•General sensory(general somatic afferent)-General sensation from the skin of the

concha of the auricle and from a small area behind the ear.
The facial nerve is
responsible for:

I. Contraction of the
muscles of the face

II. Production of tears from a

gland (Lacrimal gland)

III. Conveying the sense of

taste from the front part
of the tongue (via the
Chorda tympani nerve)

IV. The sense of touch at

auricular conchae
LEVEL OF NERVE INJURY AND SYMPTOMS
 FACIAL PARALYSIS

 Commonly Unilateral

 Nuclear- from
destruction of the
nucleus

 Central or cerebral or
Supranuclear

 Peripheral- from a lesion

of the nerve
 NUCLEAR LESIONS

 Supranuclear lesions-
usually a part of hemiplegia,
only the lower part of the
face is paralysed. The upper
part (frontalis and part of
orbicularis oculi)escapes due
to bilateral representation in
the cerebral cortex.

 Infranuclear lesions- entire

face is paralysed, as seen in
bell’s palsy
 ETIOLOGIC CLASSIFICATON OF FACIAL
PALSY
Various classification have been suggested in this
respect.
Based on:
 Course of the nerve

 Various etiologic causes

 Degree of dysfunction observed

 INTRACRANIAL (CENTRAL) CAUSES

Vascular abnormalities
CNS degenerative diseases
Tumours of the intracranial cavity
Trauma to the brain
Congenital abnormalities and agenesis
 INTRATEMPORAL CAUSES

Bacterial and Viral infection

Cholesteatoma
Trauma- blunt temporal bone trauma,
longitudinal and horizontal fractures of the
temporal bone and gunshot wounds.
Tumours invading the middle ear, mastoid and
facial nerve
Iatrogenic causes
 EXTRACRANIAL CAUSES

Malignant tumours of the parotid gland

Trauma
Iatrogenic causes
Primary tumours of the facial nerve
Malignant tumours of the ascending ramus of the
mandible, pterygoid region and skin.
 RAINER SCHMELZEISEN CLASSIFICATION
 CONGENITAL
 Moebius Syndrome
 Myotonic dystrophy
 Melkersson Rosenthal syndrome
 Congenital Cholesteatoma
 Birth injuries
 Osteopetrosis
 NEUROLOGIC
 Myasthenia Gravis
 Multiple Sclerosis
 Guillain Barre syndrome
 NEOPLASTIC
 Facial nerve tumours
 Glomus tumours
 Meningiomas, acoustic
neuroma
 Parotid tumours
 Temporal bone/external
auditory meatus tumours
 INFECTIONS
 Otitis media, mastoiditis
 Bacterial causes
 Viral causes
 HOUSE-BRACKMAN(1985) CLASSIFICATION
• Grade I-normal function without weakness.
• Grade II-mild dysfunction with sligth facial asymmetry
with a minor degree of synkinesis.
• Grade III-moderate dysfunctions-obvious, but not
disfiguring, asymmetry with contracture and/or
hemifacial spasm, but residual forehead motion and
incomplete eye closure.
• Grade IV-moderately severe dysfunction- obvious,
disfiguring asymmetry with lack of forehead motion and
incomplete eye closure.
• Grade V-severe dysfunction-asymmetry at rest and only
slight facial movement.
• Grade VI-total paralysis-complete absence of tone or
motion.
 Infectious/Idiopathic
Melkerson-Rosenthal syndrome
Congenital Ramsay-Hunt
MÖbius syndrome Otitis media/mastoiditis/meningitis
Myotonic dystrophy Lyme Disease
Necrotizing Otitis externa
HIV, TB, EBV, syphillis
Tetanus
Neurologic
Guillian-Barre Facial Systemic
Myasthena Gravis Paralysis Sarcoidosis
Stroke Amyloidosis
Multiple sclerosis Hyperostosis

Toxins/Trauma
Tumor
Head trauma
Parotid
Temporal bone trauma
Acoustic neuroma
Birth trauma Endocrine Glioma
DM Meningioma
Pregnancy Facial neuroma
Hyperthyroidism
 BELL’S PALSY
• It is defined as an idiopathic
paresis or paralysis of the facial
nerve of sudden onset.
• The name was ascribed to SIR
CHARLES BELL, who in 1821
demonstrated the separation of
motor and sensory innervation of
face.
• INCIDENCE-15-40 cases per 1 lakh cases

• SEX PREDILECTION- women more affected

than men.3.3 more times common in
pregnancy and in the third trimester.

• AGE- can occur at any age, common in middle

aged people.

• SIDE INVOLVMENT- can be equally seen,

usually unilateral.
CLINICAL FEATURES

• There is sudden onset, usually pt gives h/o

occurrence after awakening early morning.

• Unilateral involvement of entire side of the

face.

• Abrupt loss of muscular on one side of face.

• Inability to smile, close the eye or raise the

eyebrow on affected side.

• Whistling is not possible.

• In an attempt to close eyelid, the eyeball
rolls upward.

• Inability to wrinkle forehead or elevate

upper or lower lip.

• Obliteration of nasolabial fold.

Face appears distorted and mask like

appearance to the facial features.

Speech becomes slurred.

Occasionally there is loss or alternative of

taste.
Partial paralysis always resolves completely within a few
weeks.

Recovery from complete paralysis takes longer (months)

and is complete in only about 60-70% of cases.

Approximately 15% of patients are left with troublesome

residual palsy and or synkinesis.
 COMPLICATIONS OF FACIAL PARALYSIS

Facial paralysis severely hinders:

• Normal facial expressions
• Mastication
• Speech production
• Eye protection.
 Psychological Trauma
• The most significant complication is the social
isolation these patients often succumb to.
The most serious complication is corneal damage.
One of the greatest problems with Bell's palsy is the involvement of
the eye if the lid fissure remains open.
In this case, eye care focuses on protecting the cornea from
dehydration, drying, or abrasions due to insufficient lid closure or
tearing
 ASSESSMENT AND PLANNING

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
 EVALUATIONS OF NERVE FUNCTION

• 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
• Nerve excitability tests.
• TEAR TEST: (Schirmer’s test)
• Semiquantitative method for comparing lacrimal
secretion on normal & affected side.
• 0.5×5cm strip of filter paper.
• If moistened length in affected side <25% of
normal: significant hyposecretion is present.
 TASTE
CHORDA TYMPANI:
• Subjective loss of sensation: unreliable symptom.
• Swab sides of tongue by a cotton applicator dipped in lemon juice.
• Threshold measured with electrogustometer (measured electric
current). N:30gk microamp
• Patient percieves this as sour or metallic.

SALIVARY FLOW
• Cannulate wharton duct on each side with no.50 polyethylene tube
• Stimulate saliva with lemon juice
• Output of saliva measured in each tube
• 25% reduction is significant
• Indicates interruption of chorda tympani or facial nerve to this branch.
• LIMITATIONS- Unequal penetration of cannula, assymetry of glands.
 ELECTRICAL TESTING OF FACIAL NERVE

MAXIMUM STIMULATION TEST

• Pulsed electric current is delivered through a cutaneous
electrode
• Short pulse will stimulate an intact nerve & elicit a
muscular twitch.
• In paralysed facial nerve, this indicates that lesion is
neuropraxia & distal neurons have not undergone
degeneration
• Hence differentiates between neuropraxia & axonotmesis:
prognostic value.
NERVE EXCITABILITY TEST:
• Current required for stimulation on normal side is compared with
paralysed side.
• Disadv: even few intact fibres can elicit a response when rest in
undergoing degeneration.
Muscle twitch response is subjective
Uncomfortable procedure
Requires patient co-operation

ELECTRONEUROGRAPHY
• Measures compound action potential in facial muscles in response to
facial nerve stimulation.
• Similar to MST, except instead of visually ration the muscle
contraction, the muscle action potential is measured on EEG- more
accurate.
• Best test to predict & follow facial nerve recovery.
• Compare & represent it as percentage of normal side.
 Treatment

• Oral antivirals - Acyclovir

• Corticosteroids
• Eye protection
• Follow progression with serial exams
• Physiotherapy
 MEDICATION

• 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.
• If pt is seen after 3-4 weeks, then steroid therapy
is of no use.
 SURGICAL TREATMENT MODALITIES

• Nerve decompression - Internally or externally

• Nerve anastomosis

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

Ryan Ridley. Facial Reanimation .Grand Rounds Presentation, UTMB, Dept. of Otolaryngology
 Micro-neurological Surgery
• 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.
 PRIMARY NERVE REPAIR

 End-to-end
anastomosis preferred
No tension
 Extratemporal repair
performed < 72 hrs of
injury
 Most common methods
Group fascicular repair
Epineural repair Group fascicular repair
 Primary Nerve Repair
 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 TECHNIQUE
 Epineural repair recommended
for injury proximal to pes
anserinus and intratemporal
 INTERPOSITION GRAFTING
 Cable grafts
 Used when defect > 17mm; nerve cannot be
reapproximated without tension
 Most common
 Greater Auricular Nerve
 Sensory nerves from superficial cervical plexus
 Sural nerve
 INTERPOSITION GRAFTING GREATER AURICULAR
NERVE
 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

 Advantages:
 Proximity to facial nerve
 Cross-sectional area
 Limited morbidity
 Limitations:
 Reconstruction of long defects
 Ideal for defects < 6cm in length
 SURAL NERVE
• Anatomy
– Formed by union of medial
sural cutaneous nerve and
lateral sural cutaneous branch
of peroneal nerve.

 Advantages :
 Length : >12cm
 Accessibility
 Low morbidity associated with
sacrifice
 Disadv:
 Variable caliber
 Often too large
 Difficult to make graft approximation
 Unsightly scar
 NERVE TRANSPOSITION/ CROSSOVER

• Nerve transposition is also known as facial-

hypoglossal transfer.
• 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.

51
 CROSSOVER TECHNIQUES

 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

 Adv:  Disadv:
 Time interval until movement  Donor site morbidity
4-6 months  Some degree of synkinesis
 Avoid multiple sites of anastomosis
 Mimetic-like function achievable with practice
 Hypoglossal-Facial Technique
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 c m of main trunk of the
facial nerve
4. Hypoglossal nerve is dissected
anteriorly and medially into the
tongue.
1. Transect distal to ansa
hypoglossis
5. Facial nerve transected at the
stylomastoid foramen
6. Anastomose nerves using 9-0
 Hypoglossal Facial Nerve Transfer

Entire hypoglossal nerve 40% segment of nerve secured to

transected lower division.

Hypoglossal nerve
reflected superiorly

54
 Hypoglossal Facial Nerve Transfer

Reflection of the facial nerve

Jump graft modification out of the mastoid bone.

55
 CROSS-FACIAL NERVE GRAFTING

• 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
– 2nd surgical site
– Violation of the normal facial nerve
 CROSS-FACIAL NERVE GRAFTING

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.
 MUSCLE TRANSPOSITION
(“DYNAMIC SLING”)
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
TEMPORALIS
 Often used for reanimation of
the oral commisure.
 Middle 1/3 of muscle is best for
transfer (Sherris, 2004)
 Temporalis Transfer
1. Incision in preauricular crease
extending to superior temporal
line
2. Obtain wide exposure of
temporalis muscle by dissecting
above the SMAS
3. Incise down on periosteum to
elevate muscle fibers
-Harvest middle 1/3
4. Large tunnel created over
zygomatic arch
5. Orbicularis oris muscle exposed
via vermilion border incision at
oral commissure
6. Large tunnel over zygomatic arch
used to connect oral commisure to
zygomatic arch/superior incision.
7. Temporalis flap detached and
elevated from its origin and
tunneled to the oral commissure.
8. 3-0 prolene used to suture
orbicularis to temporalis at oral
commissure
9. Overcorrection of nasolabial fold
and oral commissure
 MASSETER
• Used when temporalis muscle is not opted.
• May be preferred due to avoidance of large facial
incision
• Disadvantage:
– Less available muscle compared to temporalis
– Vector of pull on oral commisure is more horizontal
than superior/oblique like temporalis
 Masseter Transfer
1. Expose muscle with gingival
incision along mandibular sulcus
2. Dissection carried out in a plane
between mucosa and muscle.
3. Muscle freed off of mandible
medially and from the
inferiolateral edge of mandible.
4. Vertical incision made in inferior
portion of muscle
5. Anterior half of muscle is split
into 2 divisions.
6. The 2 anterior slips of muscle are
tunneled anteriorly to reach the
oral commisure via external
vermillion border incisions
7. Muscle slips are attached to lips
and oral commisure in the deep
dermal layer using suture
 MICRONEUROVASCULAR TRANSFER
FREE MUSCLE FLAPS

• They have potential of achieving individual

segmental contractions
– Reduction of synkinesis
• Muscle flaps used are:
– Gracilis
– Latissimus dorsi
– Inferior rectus abdominus
 MICRONEUROVASCULAR TRANSFER
FREE MUSCLE FLAPS

 Requires viable muscle and nerve innervation

 Traditionally done in 2 stages
 1st: Cross-face nerve graft ~ 1 yr prior to muscle transfer
 2nd: Muscle transfer performed after neural ingrowth of graft
 GRACILIS Anterior Obturator nerve
Adductor a. & v.
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 vessels.
5. Obturator nerve of gracilis
connected to distal end of sural
nerve graft.
 ADDRESSING PARALYTIC EYELIDS
 Complications of orbicularis oculi paresis
 Delayed blinking
 Impairment of nasolacrimal system
 Dry eye
 Risk of exposure keratitis, corneal ulceration and
blindness
 Goal of treatment is to maintain cornea
 Treatment Options
 Tarsorrhaphy
 Gold weight/spring implants
 Open / endoscopic brow lifts for significant brow ptosis
GOLD WEIGHT
IMPLANTATION
1. Small incision
made several
millimeters above
the upper eyelid
margin.
2. Tarsal plate
exposed with sharp
dissection
3. Gold weight
secured to tarsus
using 8-0 nylon.
4. Wound closed in 2
layers
 TARSORRHAPHY
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.
 Surgical management of LAGOPHTHALMOS

• F. Stagno d’Alcontres, G. Cuccia*, F. Lupo, G. Delia, M. RomeoThe

orbicularis oculi muscle flap: Its use for treatment of lagophthalmos. Journal
of Plastic, Reconstructive & Aesthetic Surgery (2010) 63, 416e422
 STATIC PROCEDURES
• Static Facial Suspension is used to lift the corner
of the mouth so that balance is restored to the face
and drooling out of the mouth is helped.
 Indications:
 Debilitated individuals; poor prognosis
 Nerve or muscle not available for dynamic procedures
 Adjuct procedure with dynamic techniques to
provide immediate benefit
 Advantages:
 Immediate restoration of facial symmetry at rest
 No oral commisure ptosis
 Drooling, disarticulation, mastication difficulties
 Relief of nasal obstruction caused by alar collapse
 STATIC SLINGS
 Variety of materials
used
• PTFE (Gor-Tex)
• Alloderm
• Fascia lata
 Gor-Tex and alloderm
have advantage of no
donor site morbidity
but higher risk of
infection.
 STATIC FACIAL SLING TECHNIQUE
1. Preauricular, temporal or nasolabial
fold incision may be used
2. Additional incisions made adjacent
to oral commisure at vermillion
border of upper and lower lip
3. Subcutaneous tunnel dissected to
connect temporal to oral
commisure incisions
4. Dissection may be carried out in
midface adjacent to nasal ala, if
needed (for alar collapse)
5. Implant strip is split distally to
connect to the upper/lower lips
6. Implant secured to orbicularis
oris/commisure using permanent
suture
7. Implant is suspended and anchored
superiorly to superficial layer of
deep temporal fascia, or zygomatic
arch periosteum, using permanent
suture.
8. May also secure to malar eminence
using small miniplate or bone
anchoring screw
 REFERENCES

• Cranial nerves-Functional Anatomy – Stanley Monkhouse

• Anatomy for Surgeons: Hollinshead
• Maxillofacial surgery: Peter Ward Booth Vol 1 & 2
• Peterson’s Principles of Oral & Maxillofacial Surgery, 2nd edition.
• Oral pathology- Regezi.
• Textbook of oral surgery – Neelima Malik
• Gray’s anatomy.
• Text of Anatomy by Roylce.
THANK YOU THANK YOU