6.3 Facial Palsy.pdf

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C:\Users\Zeeshan\Documents\My Dropbox\frcs(plast) notes and papers\Reinstalled frcsplast.com\1.FRCS(Plast) Revision Notes\06. Ear Eyelid Nose & Vasc Anomalies\6.3 Facial Palsy.doc

6.3 FACIAL PALSY

Anatomy of the facial nerve

The facial nerve supplies the structures derived from the second branchialarch.

It is the seventh cranial nerve and is motor to the muscles of facial expression. It originates from the pontine region of the brain stem and enters the temporal

bone at the internal auditory meatus, alongside the eighth cranial nerve. It emerges as two routesthe larger motor route and the smaller nervus

intermedius that carry taste and parasympathetic and sensory fibres It traverses the internal acoustic meatus, facial canal and parotid gland Within facial canal, it gives off:

1. Greater petrosal nerve secretomotor tear secretion from thelacrimal gland and glands of palate

2. Tympanic nerve small sensory branch3. Nerve to stapedius acts to dampen loud noises.4. Chorda tympani supplies taste to the ant 2/3 of the tongue, travels

with the lingual nerve.

It then emerges from the stylomastoid foramen:1. Posterior auricular nerve occipital muscles and sensation to small area

behind earlobe.2. Nerve to posterior belly of digastric and stylohyoid Then divides into upper temporozygomatic branch and lower cervicofacial

branch. Within the substance of the parotid gland each branch divides andrejoins only to divide again into the 5 terminal branches.

1. Temporal (frontal) travels along Pitanguys line from 0.5 cm below thetragus to 1.5cm above and lateral to the eyebrow. The frontal branchbecomes increasingly superficial as it travels upwards. It lies just deep to thetemporoparietal (superficial temporal) fascia in the temple. Lower motorneurone lesions of the facial nerve or its frontal branch result in paralysis of the

ipsilateral frontalis muscle.2. Zygomaticbranch divides into branches supplying the orbicularis oculi

muscle, division results in an inability to close the eye.


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3. Buccalbranch divides into multiple branches travelling along side theparotid duct supplying the buccinator and the muscles of the upper lip.Division causes trouble emptying the cheek.

4. Marginal Mandibular runs just below the border of the mandible deep tothe platysma and superficial to the facial vein. It supplies the muscles of thelower lip. Division of this nerve results in elevation of the corner of the mouth.

5. CervicalBranch runs downwards into the neck to supply the platysma. There is a significant degree of crossover between the buccal and zygomatic

branches so can get some crossover innervation, little crossover for the frontal ormarginal mandibular.


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Congenital VII Palsy- Neonatal Facial Paralysis

Obstetric facial paralysis - forceps Mbius syndrome1888

Defect in development of facial nucleus 6th and 7th nerve palsies Paralysis of VII and VI characterised by bilateral facial paralysis May also involve III, V, IX and XII Limb abnormalities present in 25% Pectoral abnormalities present in 15% MVH avoid nerve grafts and use LD, IX as donor nerve to attach LD n directy

on to.

CLUFT abnormalities in Mobius - Abrahams PRS 1988 Cranial nerves Lower Limb Upper limb Facial Thoracic

Treatment of Mbius Syndrome Cant use other site for source of nerve innervation so use another nerve

for innervation of free muscle transfer. Ipsilateral accessory, Trigeminal,

ipsilateral hypoglossal but often abnormal so not suitable


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Goldenhars syndrome Hemifacial microsomia Epibulbar dermoids May have assoc facial nerve abnormality

Acquired Facial Paralysis

Causes of Facial Palsy

Systemic Causeso Pregnancyo DMo hypo/hyper thyroido leado tetanuso diphtheriao carbon monoxide

Central Causeso Intracranial - tumour/trauma/congenital

Tumours - CNS Masses, Extracranial Masses - parotid,cholesteatoma

Multiple Sclerosis Polio Mbius

Intratemporalo Bells palsyo Trauma, incl. iatrogenico Otitis mediao Cholesteatomao Acoustic Neuromao Infection - Herpes Zoster oticus (Ramsay Hunt Syndrome)o Tumours of middle ear

Extratemporalo Traumao Tumoursof the facial nerve, maxilla/mandibleo Parotid Malignancy - esp. acinic cell- perineural invo Iatrogenic injury

Bells Palsy (Charles Bell 1814)

Originally facial palsy from any cause now idiopathic only, diagnosis ofexclusion.

10% labelled with this have other cause May be caused by a viral infection producing swelling of the nerve within its

tight intratemporal course. 1/60 lifetime risk, 20/100,000 90% full or nearly full recovery (50% full) - incomplete paralysis is a good sign Most patients regain full facial nerve function and usually start to improve

after 4 weeks. In severe cases complete axonal degeneration occurs taking 3

months to signs of recovery and may be incomplete.


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Facial Palsy Assessmentloads out there House & Brackman Scale

o Graded 1-6:o Essentially: Normal-Mild-Mod-Severe-Very Severe-Total.

Facial grading scale (Ross) Facial Disability Index Burres Fisch - Lots of numbers Nottingham Score - Jonathan Britto likes it. Or use MRC grade

House and Brackman (in more detail):

Grade 1 some mimetic (spontaneous) movement Grade 2 no mimetic Grade 3 only mass action of facial muscles Grade 4 unable to completely close eyelids Grade 5 symmetry despite complete paralysis Grade 6 an asymmetrical face with no movement

Evaluation

History - insidious vs. rapid Blunt vs. sharp trauma Assess Bells Phenomenon! Protect the eye! Total vs. Partial, unilateral vs bilat, symmetry at rest and dynamicthere

will be some residual function almost always. Look for synkinesis and areas of over-innervation Cranial N. examination Brow ptosis/Ectropion(late)/Oral incompetence NL Fold/Malar prominence asymmetry Nasal tilt - scoliosis - away from affected side Scars or signs of previous trauma, Absence of forehead wrinkles, Position and movement of upper lid Condition of the conjunctiva for evidence of exposure Ectropion of lower eyelid Position of the mouth Test strength of eyelid closure Perform eyelid SNAP test Assess nasal valving Verify that temporalis is contracting by palpating as the pt clenches jaw.

Investigation

Electroneuronography - like EMG but compare to normal side - assessedover time

Schirmers Tear Production integrity of greater petrosal nerve bymeasuring the tear production. Special filter paper in lower conjunctiva for5 mins.


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Goals of Treatment

Rest symmetry Facial function Voluntary function Spontaneous movement Absence of synkinesis

Non-operative treatment

Protection of the eye - Bells Phenomenon is present in 75% - lubricatingdrops, glasses, taping closed at night

Paralytic ectropion lateral taping Botox (clostridium botulinum) produces paralysis by interfering with the

release of acetylcholine from the motor nerve endplates. Botox to normalside of face can improve symmetry.

High dose steroids within 72hrsineffective after 7 days Antivirals

Static Operations

Tarsorrhaphy Narrows the palpebral fissure by joining the eyelids aides eye closure Temporary Tarsorrhaphy Performed when there is some expectation of

recoveryo CentralFrost Suture lower eyelid suture held to forehead with

Steristripso Lateral

Permanent Tarsorrhaphy - if little expectation of recoveryo McLaughlin Tarsorrhaphyo Post flap from lower lido Ant from uppero Outer 1/3o Lash preserving

Kuhnt-Symanowski Procedureo Split level eyelid resectiondifferential wedge excisions from

anterior and posterior lamellae (see 6.2.1 Ectropion)o Used to correct paralytic ectropion of the lower eyelido Largely obsolete now.

Gold Weights/springso Inserted into the upper lid to help closureplaced subcutaneous

over the orbicularis.o Customised vs. off the shelfo With/without anchoring holeo Trial first by taping on to outside to get weight right

Brow Lifts / Suspensiono Endoscopic or open, elevate the ptotic brow caused by paralysis

of frontalis Forehead Skin excision

o Skin excision above the eyebrow or in the temple Unilateral facelift type procedures

o Remove skin excess and improve facial symmetryo subperiosteal lift with lower lid rebalancingo thread-lift, Endotine lift etc.

Facial slingso Segments of fascia lata to elevate the corner of the mouth and

nose.o Fascia Lata on to temporalis


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Dynamic Procedures

Nerve repair or graft

Direct repairof damaged or cut nerves good functional recovery ifoptimal conditions.

Graftif gap >2cm - Gt. auricular or suralCross-facial nerve grafting (Scaramella 1970)

Sural nerve graft anastomosed to branch of the facial on the nonaffected side distal stump of the facial nerve on damaged side.

One or 2 stage op, 2 stage excise terminal neuroma after waiting for Tinelsto cross face then attaching to distal stump limited success as the facialmuscles wont reinnervate after the delay

Nerve Transfers/Substitution

Other nerves onto the distal stump, Glossopharyngeal, Hypoglossal,Accessory, Phrenic. Easy to perform, only need to cross one anastomosis,but only produce course movements, loose function of donor nerve.Hypoglossal often used after tumour resection.

Avoid babysittingdenervation of tongueMuscle Shortening or Local muscle flaps

Muscle Shortening if partially affected Masseter part or all can be transferred, divided into 3 slips and insert

above the lip, into the commissure and below the lip. Temporalis transposed and inserted around the eye, need extra

periosteal extensions or fascial grafts to elongate the musclesee EGtechnique below

SCM described but rarely used.Cross face nerve grafting and free-muscle transfer

One or 2 stage procedure. One stage muscle with long donor nerve, only have one suture line, no

nerve graft donor but not many suitable muscles, long denervation time ofthe muscle results.

Two stage Reversed sural nerve graft tunnelled from donor buccalbranch nerve to tragus. After nerve regeneration free muscle harvestedand inserted onto Zygomatic arch and distally to the mouth and nose.Positioning aims to replicate the function of zygomaticus major. Usegracilis, pectoralis minor, or LD.

Mount Vernon Technique - Dougie Harrison + Grobelaar

Prefer dynamic techniques:o 2 stages - mean 8m aparto 471 cases as of Jan 06o Pec minor 1st choice - 3 slips into upper lip, lower lip, alar base.o EDB occasionally.o Gracilis never

Julia Terzis says - Pec minor is a 'clever' muscle - small motor units. LD isstupid

Manfred Frey says - need 3rd stage fiddlesEast Grinstead TechniqueCharles Ndukaearly experience (June 07)

Functional muscle transfer:o Prefers temporalis techniquesadapted from Fausto Viterbo (Brazil)

and Daniel Labbe (Caen, France)o (Fausto Viterbo proved can do end-side nerve anastomosis)


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o Temporalis transfer Retrograde (mid portion only taken - criticised as the muscle is

now trying to raise mandible as well as raise smile - relativelyopposing actions

Orthograde - McLaughlin - coronoid process insertiondetached and transferred with tendon graft

Orthodromicin-line transfer of temporalis:o Daniel Labb - PRS 1996 - bicoronal approach, zygomatic arch x2

osteotomies, coronoid detached tunnelled through fat pad to avoidskin-tether, insertion beyond NL-fold - no tendon graft - i.e. bothinsertion and origin are released (nerve stim used to check). Now usingcross-face graft to help sync of both sides -

o Reliable surface marker - Base of nose to tragus - 2cm anterior totragus is Zygomatic branch

Charles Ndukas criticisms of Free Muscle Transfero Pec minor - only Grobelaar in UKo 2-stage, so slower rehabo Bulkyo nerve often does not reach in kids - head relatively big c.f. muscle,o long interval from start of surgery to facial movements appearing

Results:

Mike Poole's Hay's Score vs Dougie Harrisson's PRS 1985 - 1,2,3 score -younger get better results. ???

Facial Palsy OphthalmologyCornelius Rene Manchester 23 Mar07

Problems

Corneal exposure Paralytic ectropion Epiphora Poor cosmesis

Assessment

Vertical palpebral aperture Lagophthalmosinability to close eye completely Lid position Lower Lid laxity Corneal exposure Corneal sensation Bells Phenomenon Brow Ptosis

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