NEURAL DISEASES OF THE EAR

PROF.H.C.TANEJA

INFRANUCLEAR FACIAL PARALYSIS

Commonest cranial nerve lesion.
APPLIED ANATOMY OF FACIAL NERVE
1. Motor fibres - to muscles of facial expression
-buccinator,stapedius,digastric,stylohyoid
2. Secretomotor parasympathetic fibres
lacrimal,nasal, submandibular & sublingual
salivary glands.
3. Taste fibres anterior 2/3rd of tongue

CAUSES OF I.N.FACIAL PALSY

A. INTRACRANIAL
a)In the brainstem
1)Vascular : thrombosis , embolism, haemorrhage
of vertebrobasilar artery.
2)Trauma to brainstem
3)Infections : polio, diphtheria, infective
polyneuritis
4)Tumours
5)Disseminated sclerosis

b) between brainstem and the internal auditory

meatus
1) Trauma 1.fracture of base of skull
2.excision of acoustic neuroma
3.surgery of trigeminal ganglion
2) Meningitis
3) Tumours - acoustic neuroma, tumours of
c.p.angle

B) INTRATEMPORAL ~90%
Bells palsy~66%

1)Idiopathic bells palsy

2)Trauma
1.head injuries with fracture temporal bone
2.postoperative
3.penetrating injuries of middle ear
3)Infections
1.complications of ASOM/CSOM (unsafe type)
2.Herpes zoster (ramsay-hunt syndrome)
4)Tumours
5)Iatrogenic

 C) EXTRACRANIAL
1)Trauma 1.birth trauma
2.facial injuries
3.post operative-a)low post aural incision
b)after parotidectomy
2)Tumours 1.metastatic lymph nodes
2.parotid tumours

 D) GENERAL
Diabetes
Lead poisoning
Infections polio ,diphtheria ,syphilis ,
sarcoidosis

BELLS PALSY
Most common type of idiopathic infranuclear facial
nerve palsy
AETIOLOGY
1. Age: any age
peak incidence in 3rd & 4th decade
2. Sex: equal
3. Vasospasm : blood vsl. Of facial nv. near
stylomastoid foramen
4. Virus
5. Allergy
6. Idiopathic

 PATHOLOGY
Vasospasm
primary ischemia
edema
of connective tissue
nerve compression
secondary ischemia.

 CLINICAL FEATURES
1) Onset :sudden, at night during sleeping
2) Pain :+/- behind ear before or after onset
3) Features of palsy
- loss of wrinkling on ipsilateral forehead
-loss of ipsilateral eye closure
-deviation of angle of mouth towards normal
side
-buccinator muscle palsy
-taste may be lost on affected side
-reduced lacrimation & salivation
-ear & CNS- WNL

 PROGNOSIS
75% recover within 2-3 wks
10% recover slowly
15% no recovery

 DIFFERENTIAL DIAGNOSIS
A) Supranuclear palsy
upper part of the face including eyelids escape
B) Infranuclear palsy
Intracranial: other cranial nerves , cerebellum & brainstem
may also be affected.
Intratemporal : 8th nerve may be involved conductive
deafness may coexist
Extracranial :
General: diabetes should be ruled out

INVESTIGATIONS
1.
2.
3.
4.
5.

Neurological examn
X-ray
Blood sugar
V.D.R.L. Test
Electrodiagnostic tests
1. Electromyography- spontaneous fibrillation
potential develops after 2-3 wks of nerve degeneration
2. Nerve excitability test-threshold raised by 4 to 5
mAmp
significant impairment of nerve func.
3. Electroneuronography- >95% degeneration after 2
wks of onset. Less likely to recover with conservative
t/t.

6. Topodiagnostic test
-schirmers test
-salivary flow test
-gustometry test-electrical
-topical
-stapedial reflex
7. Audiometry

TREATMENT

Steroids- prednisolone 40 to 60 mg/day

Vit. B1,B6,B12
Vasodilators
Care of the eye
Physiotherapy electrical stimulation-prevent muscle
degeneration active exercises.
Facial nv. Decompressionrequired in 2-3% cases
for post-traumatic facial palsy
Plastic surgery- improves cosmetic appearance
Facilitate eye closure

ACOUSTIC NEUROMA
Arises from neurilemma sheath of 8th cranial nv.
May be assoc. by von-recklinghausens dis. (may
be bilateral)
Etiology: occurs in both sexes btn 30-60 yrs age

 C/F:
Aural features- gradually progressive unilateral
S.N. deafness & tinnitus
Chronic unsteadiness
Trigeminal symptoms
Facial paralysis
Late features- cerebellar signs,involvement of
other cranial nerves, increased I.C.T

 INVESTIGATIONS:
neurological examn
audiometry
vestibular tests
radiography
TREATMENT
surgical excision