FACIAL NERVE

(CRANIAL NEVRE VII)

 Anatomy
• Is a mixed cranial nerve
• Arises in Pons that has different nuclei
- motor root - from facial nucleus giving motor fibers
- parasympathetic root - from superior salivary nuclei sending fibers
to salivary and glands
- the nucleus of tractor solitaries receive fibers
from anterior 2/3 of tongue

- sensory - at trigeminal nucleus that receive touch, pressure and pain

fibers from the tongue
- Can be divided into four functional components
- two efferent fibres
- two afferent fibres
• There are four major functions of the facial nerve:
• General somatic efferent (motor supply to facial muscles)
• General visceral efferent
(parasympathetic supply to submandibular, sublingual salivary
glands and lacrimal gland)
• Special visceral afferent
(taste sensation from anterior two-thirds of the tongue)
• General somatic afferent
(cutaneous sensations from the pinna and the external
auditory meatus)
• One group of efferent fibres
- arises from the motor nucleus of facial nerve and innervates
- posterior belly of digastric muscle
- stylohyoid muscle
- stapedius muscle
- muscles of facial expression
• The second group of efferent fibres
- consist of parasympathetic fibres responsible for
lacrimation
salivation
• One group of afferent fibres
- transmit sensation of taste from anterior 2/3 of tongue
to nucleus tractus solitarius
- through the sensory root of the facial nerve
(a complex path through lingual nerve, chorda tympani,
and then nervous intermedius)

• The second set of afferent fibres

- conduct sensation from specific areas of the face such as
concha, external auditory canal, and ear lobe
 Course of the nerve
• Can be divided into six segments
1. Intracranial segment
- from brain stem to internal auditory canal (IAC)
2. Meatal segment
- from the fundus of IAC to meatal foramen
- where it runs anterior to cochlear nerve
3. Labyrinthine segment
- from meatal foramen to geniculate ganglion
- gives out 1st branch – greater superficial petrosal nerve
- the fallopian canal is narrowest within this segment
4. Tympanic segment
- at the geniculate the nerve makes a 40 – 80 degree turn
proceed posteriorly across the tympanic cavity towards the
pyramidal eminence
- most facial nerve injuries in post ganglion segment occur here
5. Mastoid/Vertical segment
- from the pyramidal process to the stylomastoid foramen
6. Extratemporal segment
- from the stylomastoid foramen to the muscles of innervation
• The nerve then courses anteriorly and inferiorly towards the posterior
wall of parotid gland
• Within the gland, divides into
- an upper temporo-zygomatic division
- a lower cervico-facial division
• An extensive network of anastomose, pes anserinus, occurs between
the branches
• Ultimate components then exit the parotid gland
(temporal, zygomatic, buccal, marginal mandibular and cervical)
Muscle innervation
• Separate fibres ………………………. - stylohyoid muscle
- posterior belly of digastric
• Posterior auricular branch ………. - occipitofrontalis muscle
- external auricular muscle
• Temporal division ……………………. - orbicularis oculi
- occipitofrontalis
- anterior & superior auriculares
• Zygomatic divisions ………………… - orbicularis oculi
- zygomatic muscle
• Buccal branch ………………………….. - buccinators
- around nose and mouth
• Mandibular branch …………………. - depressor anguli oris
- depressor labii inferioris
- orbicularis oris
• Cervical ………………………………… - platysma
Evaluation
• Requires thorough understanding of facial nerve function
• Knowledge of numerous conditions that may cause nerve
involvement
• Involves - detailed history
- review of systems
- physical examination
- audiometry
- radiographic studies and electrophysiologic studies
• Crucial to appropriate management are
- early presentation
- close follow-up
- proper documentation of treatment and disease course
• Typical presentation:
- a unilateral facial weakness over 2 – 3 weeks
- specific event or day of onset is not known

* Any palsy demonstrating progression beyond 3 weeks or lack of

improvement after 6 months should be considered a neoplasm
until proven otherwise *
• Coexistence of prolonged facial palsy with
- facial twitching
- an additional cranial nerve involvement or
- sensorineural hearing loss
is highly suggestive of a tumour
• Bell’s palsy usually present with
- numbness in middle and lower face
- otalgia
- hyperacusis
- diminished tearing
- an altered taste
• HZ oticus will in addition to other presentations
- vesicular eruptions of the face and the ear
- sensorineural hearing loss and
- vertigo
• History should be obtained in detail regarding
- past and current medical conditions
- previous ear diseases
- medication and exposure to risk factor (e.g. ticks)
• Physical examination focuses on
- motor function of the facial nerve
- whether lesion is complete or partial
• Assessment of central versus peripheral involvement is done
• Central unilateral facial paralysis involves only the lower face
(innervation of upper face is derived from crossed & uncrossed
fibres)
• Peripheral nerve lesions involve both upper & lower face
• Presence of facial expression, lacrimation, taste & salivation on
ipsilateral side suggest a central lesion
- (functions not governed by motor cortex (remain unaffected)
Upper & Lower motor Neurons
• Upper motor neuron (UMN) originate in the cerebral cortex motor
nuclei of the cranial nerves (CNS) in the brain stem

• Lower motor neuron (LMN) run from the nuclei in the brain stem to the
peripheral muscle.

• Corticobulbar fibre from left/right cortex cross over such that

- the upper part of face receives innervation from ipsilateral and
contralateral cortex
- the lower half of face receives innervation only from the
contralateral cortex
• UMNL - produce paralysis of muscles in the lower half of the
contralateral side of face
- intact emotional movements

• LMNL - there is paralysis of muscles of the whole face (lower &upper)

on the ipsilateral side
Common causes of facial nerve palsy
Idiopathic
- Bell’s palsy
- recurrent facial palsy
Congenital
- Moebius syndrome
-congenital unilateral lower lip
paralysis
- Melkersson – Rosenthal synd
-Dystrophic Myastonia
Traumatic
- temporal bone fracture
-intrauterine compression
- birth trauma
- facial contusion/laceration
- penetrating wounds to the face
or temporal bone
- iatrogenic injuries
Infection Neoplasia
- HZ oticus (Ramsay Hunt Synd) - cholesteatoma
- OME - carcinoma (primary/metastasis)
- acute mastoiditis - acoustic neuroma
- meningioma
- malignant otitis externa
- facial neuroma
- ASOM
- leukemia
- tuberculosis
- hemangioblastoma
- lyme disease Metabolic/Systemic
- AIDS - DM
- infectious mononucleosis -hyperthyroidism
- encephalitis -autoimmune disorders
- sarcoidosis -multiple sclerosis
Diagnosis of lesion from level of impairment
Level of Signs Diagnosis
impairment
Supranuclear Good tone Cerebrovascular accident
Intact upper face trauma
Spontaneous smile

Nuclear Involvement of VI & VII cranial nerves Vascular or neoplastic

Corticospinal tract signs Poliomyelitis, multiple
sclerosis,
encephalitis
Angle Involvement of the vestibular & Neurinoma
cochlear portions of VIII cranial nerve Miningioma
(facial nerve, esp taste, lacrimation Fracture
and salivstion) Cholesteatoma
Arachnoid cyst
Geniculate Facial paralisis Herpes Zoster oticus
ganglion Hypercusis Bell’s palsy
Alteration of lacrimation, salivation Cholesteatoma,
and taste neurinoma
Arterovenous
malformation
meningioma

Tympanomastoid Facial paralysis Bell’s palsy

Alteration in salivation & taste Cholesteatoma
Lacrimation intact Fracture
infection

Extracranial Facial paralysis (usually a branch is Trauma

spared) Tumour
Salivation & taste intact Parotid carcinoma
Deviation of jaw to normal side Pharyngeal carcinoma
Other tests for valuation of nerve lesion
Radiologic Tests
- Need is based on history and clinical course of disease
- CT scan is best for bone assessment (integrity of fallopian canal)
- Gives information on mastoid air cells, middle ear
- MRI gives best results when evaluating soft tissues
( detects neuronal enhancement from infection or neoplasm)
*not advantageous in evaluating Bell’s palsy or Ramsey Hunt syndrome
Prognostic Tests
- understanding of pathophysiology of nerve injury crucial to
understanding of disease & determining prognosis
- depending on mechanism of lesions, there are three categories of
neural lesions
a) Neuropraxia
- blockage of axonal transport due to compression
- nerve not permanently damaged
-normal function restored when compression removed
b) Axonotmesis
- axonal integrity disrupted but endomneural sheaths are
preserved
- Wallerian degeneration distal to point of injury
- complete recovery when endoneurium preserved
c) Neurotmesis
- destruction of axon and surrounding support cells
- has Wallerian destruction
- regeneration potential is unpredictable
- high likelihood of significant dysfunction
• Other tests include
- electromyography
- electroneurography
- lacrimal (Schirmer’s) Test
- stapedial reflex test
- trigeminofacial (Blink) Test
- salivary flow test
- electrogustometry
Idiopathic facial Paralysis
(Bell’s Palsy)
• The most common form of facial palsy
• Most common in the 3rd decade of life
• Etiology not concretely known but several theories suggested
- ischemic neuritis
- viral infection
- polyneuropathy
- entrapment neuropathy
• Numerous factor may lead to the characteristic signs/symptoms
• common pathophysiology of nerve damage irrespective of the
precipitating event

- an external stimulus causes inflammation of nerve within bony

canal

- the resultant swelling leads to entrapment and ischemia

- this ischemia results in further inflammation and edema

- this creates a cycle of injury

• Is a unilateral facial weakness of sudden onset

• Resolves spontaneously diagnosis is considered on of exclusion

• Minimum criteria of diagnosis include

1. paralysis/paresis of all facial muscles on one side of face

2. sudden onset

3. absence of signs of central nervous disease or cerebellopontine

angle disease
• Besides paralysis Bell’s appears to have characteristics such as
- a viral prodrome
- numbness or pain of ear, face or neck
- dysguesia
- hyperacusis
- decreased tearing
• The palsies are - self limiting
- non-progressive
- non-life threatening
- spontaneously remitting 4 – 6 (12 months)
Evaluation

• Thorough history and physical exam

• Audiogram needed to screen the auditory system

• If complete paralysis present, electrophysiologic tests should be done

to document status and prognosis of lesion

• Complete radiologic workup necessary total paralysis is associated

with SNHL recent facial paralysis or trauma
Treatment
• Quite controversial

• Early start of steroids reported to shorten recovery time

• steroids act as analgesics

• Trials of vasodilators, vitamins and acyclovir reported

• Surgical decompression advocated for cases of total paralysis with

evidence of extensive nerve degeneration
TRAUMA
• The most commonly injured cranial nerve
• It’s course makes it vulnerable to traumatic injuries
- internal auditory canal
- middle ear
- mastoid bone
- parotid gland
• Traumatic injuries divided into
- iatrogenic
- non-iatrogenic
Iatrogenic Injuries

• injuries during mastoid and middle ear surgeries uncommon

• Common site of injury in middle ear is the tympanic segment

• Extratemporal resections (parotid & neck tumours) main cause

• Should be repaired if noted intra-operative

• If problem comes post operative then exploration and repair should be

undertaken as soon as possible
Intra-temporal Injury
• Non-iatrogenic injury following RTA or blunt trauma to the head
• Result from temporal bone fracture (longitudinal or transverse)
• Longitudinal fractures form 80 – 90%
- result from trauma to temporo-parietal area
- almost always involve the middle ear, but fewer nerve injuries
- present with - bleeding from middle ear
- laceration of TM
- conductive hearing loss
• Facial nerve injury, if present, result from compression and ischemia
as opposed to neural disruption
• Transverse fractures accounts for a much smaller proportion of
temporal bone injury
- Associated facial nerve injury present in half of the injuries
- Result from trauma to the occipito-mastoid area
- present with - hemotympanum
- vestibular symptoms
- dead ear
- nerve severance typical injury
• Gunshot wounds not very common
- may cause thermal or compression injury, not disruption
- often accompanied by CNS or vascular injury
• If paralysis is incomplete:
- conservative management
- serial exam and electrical testing to monitor progress
- steroid use may shorten recovery time

• If paralysis is complete or progressing injury:

- monitoring best with CT, audiometry, electro-neurography
- complete surgical decompression
Extratemporal Injury

• Extra-crainal nerve also susceptible to trauma

- need immediate evaluation
- electrical testing to identify injured branches
- exploration should include the surrounding areas
- repairs should be undertaken immediately
Infection
Viral

• Herpes zoster is the most common

• Distinguished from Bell’s palsy by associated findings
- intense otalgia
- vesicular eruptions (may involve TM)
- sensorineural hearing loss (SNHL)
- tinnitus
- vertige
• Combination of paralysis & vesicular eruption – Ramsay Hunt
syndrome
• Seen more in individual > 60yrs

• Reactivation of latent virus and not reinfection is mode of infection

• Diagnosis may be confirmed by rising titers of antibodies to HZ virus

• Prognosis is worse than for idiopathic paralysis

• Treatment with corticosteroids and acyclovir improves outcome

• Post herpetic neuralgia may occur and be prolonged

Bacterial
• Infections involving the ear
- acute suppurative otitis media
- chronic otitis media
- mastoiditis
- malignant otitis externa
• A dehiscence in the fallopian tube is portal of entry of bacteria
• Treatment is by oral antibiotic, middle ear evacuation
• Malignant otitis externa is treated as an emergency
Neoplasm
• May arise from the nerve or surrounding tissues
• Feature of paralysis suggesting tumour involvement
- slow evolving paralysis
- facial paralysis for > 4 months
- ipsilateral recurrence of a facial paralysis
- facial paralysis with SNHL
- presence of multiple cranial nerve deficits
- history of carcinoma
• Examples of intracranial tumours
acoustic neurinomas
- miningeomas
- adenoid cystic carcinomas
• Extra-canial tumours resulting in facial paralysis are almos exclusively
of the parotid gland
- benign tumours – pleomorphic adenomas - rarely cause facial
nerve paralysis
- malignant tumour – mucoepidermoid carcinoma – is the most
common
Paediatric facial nerve
paralysis
• Birth trauma the most common cause
• Is characterized by
- unilateral complete facial nerve dysfunction
- complicated delivery
- ecchymosis of the face or temporal region
- hemotympanum

*mastoid tip is poorly formed in infants

stylomastoid process lies just beneath the skin and makes the nerve
vulnerable at this point
EYE CARE
• Most common complication of facial paralysis is corneal ulceration
inability to close eye lids
diminished lacrimation
• Liberal application of artificial tears
• Wearing protective eye bubbles at night
• Using protective eye wears especially outdoors