Anatomy, pathophysiology, causes, types, treatment Bell's palsy, Trigeminal neuralgia

2. UNIVERSITY OF KANDAHAR
NOV/5/013
DES BY: K. WARDAK

3. • Pathophysiology
• Epidemiology
• Clinical Manifestations
• DDX
• Treatment
3
• Pathophysiology
• Clinical Manifestations
• DDX
• Management & Course
1. Kaleemullah 7mins 2. Shir Ali 6mins
3. Esmatullah 7mins
• Anatomic Considerations
• Etiology:
i. Pons
ii. CPA
iii.Petrous Temp
iv.Skull Base, Parotid
Gland…

4. TRIGEMINAL NEUROLOGY

5. • Pons:
• V1(Ophthalmic): Superior Orbital Fissure
• V2 (Maxillary): Foramen Rotundum
• V3 (Mandibular): Foramen Ovale
• Sensory: Gasserian/Trigeminal Gg (Cavernous Sinus), Asc---Pons—S.Touch;
Desc—med.obl—Pain,Heat.
• Motor: Pons---mandibular---mastication
5
Trig. Neurology/Anatomy

6. • Unilateral Sensory Loss of Cheek, Tongue, Buccal Mucosa.
• Deviated jaw (towards it)
• Blink reflex weakness/absence; primary or isolated sign.
• Brainstem lesion---Circum-oral sensory loss; spinal nucleus---pain,heat loss.
6
Trig. Neurology/Signs-Sympt

7. • Brainstem Glioma, Syringo-bulbia, MS, Infarction
• Acoustic Neuroma, Meningioma, Sec. Neoplasm
• VII, VIII---facial weakness, deafness
• If accompanied by VI, called Gradenigo’s Synd.
• Int. Carotid aneurism
• Cav. Sinus thrombosis
• Secondary Neuplasm 7
Trig. Neurology/Etiology

8. TRIGEMINAL NEURALGIA

9. • (Tic Douloureux), unilateral, idiopathic, senile
• Ectopic Action potentials in Af. Pain sensitive fibers, due to demyelination
caused by compression usually by Sup. Cerebellar Art, or tortuous vein.
• 4.5/100,000; 60% female, Middle-age or elderly (15.5/100,000).
Symptoms: Paroxysms of Excruciating pain in innervated areas. Electric
Shock, (Secs), Facial Contraction (Winces, Flinches), V3—V2---V1.
Spont, or caused by Chewing, Eating, Speaking, smiling, Shaving..
Trigger zones, No sensory loss
Signs: Corneal reflex is intact 9
Trig. Neuralgia/Patho, Signs..

10. Head and face pains:
• Jaw, Teeth, Sinuses’ pains should be distinguished.
• Migraine, Cluster headache (Consistent and Profound){Cluster Tic Synd}
Bilateral T.G.N can be a sign of MS. (Demyelination Plaque in root Entry and
facial sensory loss is manifest.)
10
Trig. Neuralgia/DDX

11. • The anticonvulsant carbamazepine is the first line treatment; second line
medications include baclofen, lamotrigine, oxcarbazepine, phenytoin,
gabapentin, pregabalin, and sodium valproate. Uncontrolled trials have
suggested that clonazepam and lidocaine may be effective
• Carbamazepine: 100mg QD (50-70% efficacy) with meal
+ 100mg/1-2 d; Usually 200mg QID(For maintenance)=>1month (taper)
• Phenytoin: 300-400mg/day.
• Baclofen: (5-10mg TID---20mg QID) In combination with either of them.
• Radio-frequency Thermal Rhizotomy (Gg. Heat)
• Glycerol in Meckel’s cave
• Neurovascular Decompression; Micro-vascular decompression (>70%)
11
Trig. Neuralgia/Treatment

12. FACIAL WEAKNESS

13. • Pons
• Pons  Internal auditory meatus  facial canal  stylomastoid
foramen  parotid gland  facial muscles
• Motor, with a sensory branch called Intermediate Nerve
13
Facial Weakness/Anatomy

14. • Facial expression muscles’
paralysis
• Drooped oral angle
• Effaced facial creases and naso-
labial folds
• Un-furrowed forehead
• Open Eyelids
• Inf. Lid Sag
• Tear drop
• Food remains between lips and
gingiva
• Oral dribbling
-------------------
• Facial Numbness
• Occasionally taste loss
• Hyperacusis
• Deafness, Tennitus, Dizziness
14
Facial Weakness/Clinical M.

15. 1. Pons:
• Pontine Tumors:
o Glioma
o Demylination,
o Vascular Lesions
2. Cerebello-Pontine Angle:
• Acoustic Neuroma
• Meningioma
• Secondary Neoplasm
3. Petrous Temporal Bone:
• Bell’s Pulsy
• Trauma
• Middle Ear Infections
• Herpes Zoster
• Tumours (Glomus Tumor)
4. Skull Base, Parotid Gland & Face:
• Dys-trophia Myo-tonica
• Facio-scapula-humeral Dystrophy
• Myasthenia Gravis
15
Facial Weakness/Etiology

16. BELL’S PALSY

17. • Common, Acute, Isolated, Unilateral, Idiopathic palsy of facial nerve.
Etiology:
• Idiopathic
• Viruses: Herpes Simplex
• Meningitis, Sarcoidosis, Lyme Disease, Tumors
Pathophysiology:
Usually Herpes Simplex type 1 DNA in Post. Auricular Muscle detectable, so
Acyclovir is prescribed.
17
Bell’s Palsy/Etiology

18. • Acute onset, within 48 hrs. reaches the ultimate weakness.
• Pain in behind the auricle (1-2days prior)
• Unilateral Taste loss
• Hyperacusis
• Salivation Decreased
• Tear Decreased
18
Bell’s Palsy/Etiology

19. • Tumors (progressive)
• Multiple Sclerosis
• Infarctions
• Bilateral Facial Paralysis in sarcoidosis.
19
Bell’s Palsy/Etiology

20. • Eye tape, to prevent Xerophthalmia.
• Muscle massage
• Gluco-corticoids (Prednisolone 60-80mg/day)
• Cosmetic surgery in Residual Paralysis
20
Bell’s Palsy/Etiology

21. • 80% spontaneous recovery (2weeks-12w or 12months)
• <10% unsightly weakness, rarely re-innervation causes unwanted
facial movements, like tear-shed caused by salivation (crocodile tears)
21
Bell’s Palsy/Etiology

22. SUMMARY

23. has 3 branches: Ophthalmic, Maxillary and Mandibular
• Has motor and sensory functions, which can be damaged at its origin or its
course.
is also termed as: (Tic Douloureux), which is unilateral,
idiopathic, senile
• Ectopic Action potentials in Af. Pain sensitive fibers, due to demyelination
caused by compression usually by Sup. Cerebellar Art, or tortuous vein.
• 4.5/100,000; 60% female, Middle-age or elderly (15.5/100,000).
Clinical Manifestations:
Symptoms: Paroxysms of Excruciating pain in innervated areas. Electric Shock,
(Secs), Facial Contraction (Winces, Flinches), V3—V2---V1.
Spont, or caused by Chewing, Eating, Speaking, smiling, Shaving..
Trigger zones, No sensory loss
Signs: Corneal reflex is intact
23
Summary

24. Pons  Internal auditory meatus  facial canal 
stylomastoid foramen  parotid gland  facial muscles
• Branches: Motor, with a sensory branch called Intermediate Nerve
Facial expression muscles’ paralysis, Drooped oral
angle, Effaced facial creases and naso-labial folds, Un-furrowed forehead,
Open Eyelids, Inf. Lid Sag, Tear drop, Food remains between lips and
gingiva, Oral dribbling Facial Numbness, Occasionally taste loss,
Hyperacusis, Deafness, Tinnitus, Dizziness
Common, Acute, Isolated, Unilateral, Idiopathic palsy of facial
nerve; causes can be: Idiopathic, Viruses: Herpes Simplex, Meningitis,
Sarcoidosis, Lyme Disease, Tumors
24
Summary

25. 1. What is Tirgeminal neuralgia?
2. What is Facial weakness?
3. What does Bell’s palsy stand for?
4. What are managerial basics of Bell’s palsy?
25
Bell’s Palsy/Etiology

26. • "Pharmacotherapy of trigeminal neuralgia“-Sindrup SH. Jensen
• Harrison’s Principles Of Internal Medicine
• Gray’s Atlas Of Anatomy
• Netter’s Atlas Of Human Anatomy
26
Bell’s Palsy/Etiology