For BDS stuents from Davidson

1. Facial Palsy/ Trigeminal
Neuralgia
Dr Avatar Verma
KIST MCTH
2076/02/10

2. Trigeminal neuralgia
• Unilateral lancinating facial pain, most commonly involving the
second and/or third divisions of the trigeminal nerve territory, usually
in patients over the age of 50 years

3. Pathophysiology
• Irritative lesion involving the trigeminal root zone, in some cases an
aberrant loop of artery
• Other compressive lesions, usually benign, are occasionally found
• Trigeminal neuralgia associated with multiple sclerosis may result
from a plaque of demyelination in the brainstem

4. Clinical features
• Pain is repetitive, severe and very brief may be triggered by touch, a cold wind
or eating
• Physical signs are usually absent, although the spasms may make the patient
wince and sit silently (tic douloureux)
• Similar in multiple sclerosis or with other brainstem lesions, in which case
there may be associated sensory changes in the trigeminal nerve territory or
elsewhere
• There is a tendency for the condition to remit and relapse over many years

5. Management
• Carbamazepine: low dose and increase gradually
• Not tolerable to Carbamazepine: Gabapentin, Pregabalin
• Amitriptyline or steroids may be effective
• The possibility of surgical treatment should be entertained, especially where response is
incomplete in younger patients
• Decompression of the vascular loop encroaching on the trigeminal root is said to have a
90% success rate
• Otherwise, localised injection of alcohol or phenol into a peripheral branch of the nerve
may be effective

6. Facial weakness
Bell’s palsy:
• One of the most common causes of facial weakness is Bell’s palsy, a
lower motor neuron lesion of the 7th (facial) nerve, affecting all ages
and both sexes
• The lesion is within the facial canal
• Symptoms usually develop subacutely over a few hours, with pain
around the ear preceding the unilateral facial weakness

7. • Patients often describe the face as ‘numb’, but there is no objective
sensory loss (except to taste if the chorda tympani is involved)
• Hyperacusis may occur if the nerve to stapedius is involved, and there
may be diminished salivation and tear secretion
• Examination reveals an ipsilateral lower motor neuron facial nerve
palsy
• Vesicles in the ear or on the palate may indicate primary herpes zoster
infection

8. • Steroids improve recovery rates if started within 72 hours of onset but
antiviral drugs are not effective
• Taping the eye shut overnight helps prevent exposure keratitis and
corneal abrasion
• About 80% of patients recover spontaneously within 12 weeks
• Plastic surgery may be considered for the minority left with facial
disfigurement after 12 months

9. • Recurrence is unusual and should prompt further investigation
• Aberrant re-innervation may occur during recovery, producing
unwanted facial movements, such as eye closure when the mouth is
moved (synkinesis), or ‘crocodile tears’ (tearing during salivation)

10. • Unlike Bell’s palsy, lesions with an upper motor neuron origin partly
spare the upper face
• Cortical lesions may cause a facial weakness either in isolation or with
associated hemiparesis and speech difficulties

11. THANK YOU