Facial Paralysis

TOPIC
DISCUSSION:
FACIAL
NERVE
PARALYSIS
- DR. SHAKUN SHARMA

Introduction
 Facial nerve is the seventh of twelve paired cranial nerves, it is
a mixed nerve with motor and sensory roots.
 It emerges from the brain stem between the pons and the
medulla, controls the muscles of facial expression.
 It functions in the conveyance of taste sensations from the

anterior two thirds of the tongue and oral cavity.
 It also supplies preganglionic parasympathetic fibres to

several head and neck ganglia.
 Facial nerve is developmentally derived from the hyoid
arch, which is the second branchial arch.
 The facial nerve is formed mainly of two parts:

1. Facial nerve proper (motor): arising from facial motor
nucleus in pons.
2. Nervus intermedius: it is the sensory root of facial nerve
lies between the facial nerve proper and vestibulcochlear
nerve in the pontocerebellar angle.
 Carrying para-sympathetic fibers (from superior salivary

 nucleus) and taste fibers ( to the solitary nucleus).
COURSE OF FACIAL NERVE
Origin: the motor fibres passes dorsally and medially
forming a loop around the abducent nucleus in the floor of the
4th ventricle forming facial colliculus and comes out at the
pontomedullary angle above the inferior cerebellar peduncle.
I- Intracranial (intrapetrosal) course
II- Extracranial course

I- The intrapetrous course:
 The nerve passes laterally with the vestibulocochlear nerve

(CN VIII) to the internal auditory meatus. At the bottom of
the meatus the nerve enters the facial bony canal where it
runs laterally above the vestibule of inner ear.
 Reaching the medial wall of the middle ear, it bends sharply

backwards above the promontory (forming its genu) where
the geniculate ganglion is found.
 It then arches downwards in the medial wall of the middle

ear to reach the stylomastoid foramen.
II- Extracranial course:
As it emerges from the stylomastoid foramen, it runs

forwards in the substance of the parotid gland crosses the
styloid process and it divides behind the neck of the
mandible into its terminal branches which come out of
the surface of the gland.
Branches of
Distribution
Facial canal Stylomastoid In face

A. Greater Petrosal foramen 1. Temporal
nerve A. Posterior auricular 2. Zygomatic
B. Nerve to stapedius B. Nerve to stylohyoid
C. Chorda tympani 3. Buccal
C. Nerve to digastric
4. Marginal
D. (posterior belly)
mandibular
5. Cervical
Testing of Facial Nerve Branches
 Testing the temporal branches of the facial nerve -

To test the function of the temporal branches of the facial
nerve, a patient is asked to frown and wrinkle his or her
forehead.
 Testing the Zygomatic branches of the facial nerve -

The patient is asked to close their eyes tightly.
 Testing the buccal
branches of the
facial nerve
 Puff up cheeks
(buccinator)
 Smile and show
teeth (orbicularis
oris)
 Tap with finger
over each cheek
to detect ease of
air expulsion on
the affected side.
FACIAL MUSCLES
 Muscles of facial expression
 Subcutaneous
 Develop from the second branchial arch
 Innervated by the VII n
1. Muscles of the scalp
2. Muscles of the auricle
3. Muscles of the eyelids
4. Muscles of the nose
5. Muscles around the mouth
6. Muscle of the neck
Facial muscle control
 These fibres come from the motor cortex of both cerebral
hemispheres.
 Half of the fibres cross over to the contralateral side and

the other half remains on the ipsilateral side.
 The facial nerve emerge from the middle of the pons and
carry motor fibres to the facial muscle.
 Passes the facial canal and exits the skull through the
stylomastoid foramen.
The innervation to the
muscles of the upper
face originates on both
sides of the brain.
The innervation to the

muscles of the lower
face comes from the
opposite side of the
brain only.
Two most common cause of acute facial paralysis are
bell`s palsy and ischaemic stroke.
Facial
Paralysis
Peripheral Central
Peripheral Facial Paralysis
 Most common is bell`s palsy.
 Bell`s palsy is an idiopathic condition, it has not yet

been possible to find out why the facial nerve
becomes compressed; however, links have been made
with viruses (including herpes, influenza and
respiratory tract infections), as well as a depleted
immune system and stress.
 It will manifest suddenly and resolves within weeks

or months.
Sign and Symptoms
 Bilateral facial muscle paralysis
 Pain in the inner ear during onset
 Impaired sense of taste
 Drooling of saliva
 Unable to close the eye properly
 Slurring of speech
 Difficulty in eating
Management
Physical therapy treatment
All procedures start together at the first session in acute lesions
(e.g: Bell’s palsy) the program starts in the third day after the
onset.
1. Sourse of deep heat: to decrease the inflammation and

applied behind the ear; for 6 sessions.
2. Electrotherapy : (faradic stimmulation)

The +ve electrode is put on the nerve trunk, while the –ve
electrode is applied on the motor point of the desired muscle.
The intensity is raised till appearance of visible contraction.
3. Exercices : (in front of mirror)
Mainly active (or passive if needed). General and/ or local
facilitatory techniques (e.g: by using resistance of the same
contralateral muscle). All the affected muscles must be
trained.
4. Splints :
Hook splints can be used for adults, starting from just below
the lower lip; raising the cheek and reaching the earlobe. In
children, adhesive plaster can be used in the same direction
of the splint.
5. Massage :
In chronic cases, deep friction massage can be used to
break down adhesions.
6. EMG Biofeedback:
Used to manage synkinetic movements, by asking the
patient to increase gradually the activity of the weak
muscle while maintaining the activity of synkinetic one
(and not increase it).This is done to decrease synkinesis
gradually.
7. Advises:
 Eye hygiene (manual closure of eye before sleep-
using eye drops and ointment as a local
decongestant and antibiotics respectively).
 Home exercises
 Avoid air draft and covering the affected area
behind the ear.
 Continuous checking the blood glucose level in
diabetic patients.
 Use ballon , o&c letters are spoken by the patient
in order to facilitate the affected muscles.
Medical treatment
 Corticosteroids :
 Prednisolone 60-80 mg/day for first 5 days and then
tapered over next 5 days
 Acyclovir 400 mg 5 times/day
 Famciclovir and valacyclovir 500 mg bid
Surgical treatment
 Facial nerve decompression
Indications:
 Complete paralysis
 ENoG less than 10% in 2 weeks
 Appropriate time for surgery is 2-3 weeks after
paralysis
Central Facial Paralysis / UMNL
 Most common due to acute stroke
 The lesion is at the spinal cord or above
 Upper motor neuron causes
 cerebral infarct (i.e. stroke)
 intracranial tumour
 multiple sclerosis
 syphilis
 HIV
 vasculitis
 There are also some rare conditions which cause facial
nerve palsies including:
 Rosenthal Melkersson syndrome: this is characterised by

seventh nerve palsy, facial oedema and tongue fissuring.
Symptoms occur from teenage years and recurrent facial
nerve palsies have been described.
 Moebius syndrome: a rare neurological disease where

children are born with facial nerve and abducens nerve
underdevelopment leading to facial muscle weakness and
inability to abduct the eyes.
B. When the cortex is injured, there's weakness in the
contralateral lower face only.
C. When the facial nerve is injured, there's weakness in the
ipsilateral upper and lower face.
Management
Physical therapy treatment
 Graduated strengthening exercises of the affected
muscles in front of mirror (through general or
local facilitatory techniques).
 Hook splint rarely used.

Evaluation of Facial paralysis
Clinical features
 Central VS Peripheral facial paralysis
 Cranial nerve evaluation.
TOPOGNOSTIC TESTING
1. Schirmer test for lacrimation (GSPN)
2. Stapedial reflex test (Stapedial branch)
3. Taste testing (Chorda tympani nerve)
4. Salivary flow rates & pH (Chorda tympani)
ELECTROPHYSIOLOGIC TESTS
1. Nerve excitability test (NET)
2. Electromyography(EMG)
3. Maximal stimulation test (MST)
4. Electroneuronography (ENoG)
House-Brackmann grading system
Schirmer's Test
 Geniculate ganglion & petrosal nerve function test
Schirmer’s test +ve when

 Affected side shows less than half the amount of
lacrimation seen on the normal side
 Sum of the lengths of wetted filter paper for both eyes
less than 25 mm
 Lesion at or proximal to the geniculate ganglion.
Stapedius reflex
 Nerve to stapedius muscle test
 Impedence audiometry can record the presence or
absence of stapedius muscle contraction to sound
stimuli 70 to 100 db above hearing threshold
 An absence reflex or a reflex less than half the
amplitude is due to a lesion proximal to stapedius
nerve
Taste (Electrogustometry)
 Chorda tympani nerve test
 Solution of salt, sugar, citrate, quinine or Electrical
stimulation
 Compares amount of current required for a response
each side of tongue.
Nerve Excitability Test
 The nerve is stimulated at steadily increasing intensity
till facial twitch is just noticeable and compared with
the normal side.
 When the difference between 2 sides exceeds 3.5
milliamps, the test is positive for degeneration.
Maximum stimulation Test: MST

 Similar to nerve excitability test, but instead of
measuring the threshold of stimulation , the current
level which gives maximum facial movement is
determined and compared with the normal side.
 Reduced or absent response indicates degeneration and
is followed by incomplete recovery.
Electroneurography: ENoG
 Facial nerve is stimulated at the stylomastoid foramen
and compound muscle action potentials are picked up by
the surface electrodes. Response of action potentials are
compared with that on the normal side.
 % of degenerating fibres is calculated :- >90% indicates
poor prognosis
 This test is most useful between 14-21 days of the onset
of complete paralysis.
Electromyography: EMG
 Tests the motor activity of facial muscles by direct
insertion of needle electrodes (usually in orbicularis
oculi & orbicularis oris) – record at rest and voluntary
contraction of muscle.
 Biphasic and Triphasic potentials - Normal resting

muscle
 Fibrillation potentials – Denervated muscle
 Polyphasic potentials – Regeneration of the nerve

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TOPIC

- DR. SHAKUN SHARMA

 It functions in the conveyance of taste sensations from the

 It also supplies preganglionic parasympathetic fibres to

 The facial nerve is formed mainly of two parts:

 Carrying para-sympathetic fibers (from superior salivary

I- Intracranial (intrapetrosal) course

II- Extracranial course

 The nerve passes laterally with the vestibulocochlear nerve

 Reaching the medial wall of the middle ear, it bends sharply

 It then arches downwards in the medial wall of the middle

As it emerges from the stylomastoid foramen, it runs

Facial canal Stylomastoid In face

 Testing the temporal branches of the facial nerve -

 Testing the Zygomatic branches of the facial nerve -

 Half of the fibres cross over to the contralateral side and

The innervation to the

 Bell`s palsy is an idiopathic condition, it has not yet

 It will manifest suddenly and resolves within weeks

1. Sourse of deep heat: to decrease the inflammation and

2. Electrotherapy : (faradic stimmulation)

 Rosenthal Melkersson syndrome: this is characterised by

 Moebius syndrome: a rare neurological disease where

 Hook splint rarely used.

Schirmer’s test +ve when

Maximum stimulation Test: MST

 Biphasic and Triphasic potentials - Normal resting

 Fibrillation potentials – Denervated muscle

 Polyphasic potentials – Regeneration of the nerve

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