This document provides an overview of facial nerve paralysis, including: - The anatomy and segments of the facial nerve from the brainstem through the skull and face. - Common causes of facial paralysis including Bell's palsy, Ramsay Hunt syndrome, and temporal bone fractures. - Evaluation involves determining if the paralysis is central or peripheral through clinical exams and tests like the Schirmer's test and stapedius reflex test. - Treatment depends on the cause but may include corticosteroids for Bell's palsy and surgery for temporal bone fractures or incomplete paralysis. Prognosis is generally good except for immediate onset paralysis.

1. Facial Nerve Paralysis
Dr Ayman Yakout
ENT Consultant
Amina Hospital Ajman

2. Outlines
 Anatomy
 Classification
 Evaluation
 Electrodiagnosis testing
 Management
 Bell’s palsy ,Ramse Hunt syndrome
 Temporal bone fracture

3. Anatomy of Facial nerve
 The facial nerve contains approximately 10,000 fibers
 7000 myelinated fibers innervate the muscles of facial
expression, stapedius muscle, postauricular muscles,
posterior belly of digastric muscle, and platysma
 3000 fibers form the nervus intermedius (Nerve of
Wrisberg)
 sensory fibers (taste) from the anterior 2/3 of the tongue
 taste fibers from soft palate via palatine and greater petrosal
nerve
 parasympathetic secretomotor fibers to the parotid,
submandibular, sublingual, and lacrimal gland

4. Anatomy of Facial nerve
1) Intracranial part
 Supranuclear segment
 Nuclear segment
 Infranuclear segment
 Cerebellopontine angle
 Internal acoustic canal
 Labyrinthine segment
 Tympanic segment
 Mastoid segment
2) Extracranial part

5. Supranuclear segment
 Cerebral cortex  Corticobulbar tract 
Facial nucleus (pons)
 Upper face  crossed & uncrossed
 Lower face  crossed only

6. Nuclear segment
 Facial motor nucleus
 lower 1/3 of Pons
 abducent nucleus
 Out from brain stem at pons recess between
olive and inferior cerebellar peduncle

8. Nervous intermedius
 Parasympathetic secretory fibers arise from
superior salivatory nucleus
 These preganglionic fibers travel to the
submandibular ganglion via the chorda
tympani nerve to innervate the
submandibular and sublingual glands
 And to sphenopalatine ganglion via greater
superficial petrosal nerve to innervate
lacrimal, nasal, and palatine gland

9. Nervous intermedius
 Secretory fibers of lesser superficial
petrosal nerve tranverse tympanic plexus,
synapse in otic ganglion, and travel via
auriculotemporal nerve to innervate
parotid gland
 Taste fibers from anterior 2/3 of tongue
reach geniculate ganglion via chorda
tympani nerve and from there travel to the
nucleus of the tractus solitarius

10. Infranuclear segment
 Cerebellopontine angle
 Internal acoustic canal
 Labyrinthine segment
 Tympanic segment
 Mastoid segment

11. Cerebellopontine angle
 The facial nerve and nervus intermedius exit the
brain stem at the pontomedullary junction and
travel with CN VIII to enter the internal
acoustic meatus

12. Internal acoustic canal
 Motor facial nerve (medial)
 Nervus intermedius (between)
 Acoustic nerve (lateral)

13. Labyrinthine segment
 Fallopian canal
 Shortest & Narrowest part
 Temporal bone
 Facial nerve enter fallopian canal until middle ear
 First genu
 Geniculate ganglion
 Branches
 Greater superficial petrosal nerve  lacrimal
gland
 Lessor superficial petrosal nerve  parotid gland

15. Tympanic segment
 First genu  above oval window  stapes
 Second genu beyond middle ear
 Out of cranium through stylomastoid foramen

16. Mastoid segment
 Stylomastoid foramen
 Branches
 Motor nerve to stapedius muscle
 Chorda tympani nerve between malleus and
incus
 secretomotor : Submandibular & Sublingual gland
 taste fiber : anterior 2/3 of tongue

17. Extracranial segment
 Posterior auricular nerve : auricularis, occipitalis
and sensation at auricular, post auricular area
 Branch to posterior belly of digastric muscle and
stylohyoid muscle
 Temporal branch : muscle above zygoma
 Zygomatic branch : orbicularis occli
 Buccal branch : buccinator and upper lip
 Marginal mandibular branch : orbicularis oris and
lower lip
 Cervical branch : platysma

18. Differential Diagnosis
1. Extracranial
2. Intratemporal
3. Intracranial

19. Extracranial
1. Traumatic
 Facial lacerations
 Blunt forces
 Penetrating wounds
 Mandible fractures
 Iatrogenic injuries
 Newborn paralysis

20. Extracranial
2. Neoplasm
 Parotid tumors
 Tumors of the external and middle ear
 Facial nerve neurinomas
 Metastatic lesions
3. Congenital absence of facial
musculature

21. Intratemporal
1. Traumatic
 Fractures of petrous pyramid
 Penetrating injuries
 Iatrogenic injuries
2. Neoplastic
 Cholesteatoma
 Facial neurinomas
 Hemangiomas
 Meningiomas
 Acoustic neurinomas

22. Intratemporal
3. Infectious
 Herpes zoster oticus
 Acute otitis media
 Chronic otitis media
 Malignant otitis externa
4. Idiopathic
 Bell's palsy
 Melkersson-Rosenthal syndrome
5. Congenital: osteopetroses

23. Intracranial
1. Iatrogenic injury
2. Neoplastic
3. Congenital
 Mobius syndrome
 Absence of motor units

24. History
 Onset
 Previous symptoms
 Complete or incomplete
 Unilateral or bilateral
 Pain
 Underlying disease (vestibulocochlear)
 Associate symptoms
 Alteration in taste or lacrimation

25. History
 Family history
 Trauma
 Hx of viral infection
 Vaccination
 DM
 HTN
 Pregnancy

26. Physical examination
 ENT exam
 Nervous system
 Location
 Severity

27. Evaluation of Facial paralysis
 Clinical feature
 Central VS Peripheral facial paralysis
 Complete head and neck examination
 Cranial nerve evaluation
 Electrodiagnostic testing
 Topographic diagnosis

28. Central facial paralysis
 Upper motor neurone lesion
 Movements of the frontal and upper orbicularis
oculi tend to be spared
 Because of uncrossed contributions from
ipsilateral supranuclear areas
 Involvement of tongue
 Involvement of lacrimation and salivation

29. Peripheral paralysis
 Lower motor neurone lesion
 At rest :
 less prominent wrinkles on forehead of
affected side, eyebrow drop, flattened
nasolabial fold, corner of mouth turned down
 Unable to :
 wrinkle forehead, raise eyebrow, wrinkle
nasolabial fold, purse lips, show teeth, or
completely close eye

30. Topographic Diagnosis
 To determine the anatomical level of a
peripheral lesion
 Lacrimation  Geniculate ganglion
 Stapedius reflex  motor nerve of stapedius
muscle
 Taste  chorda tympani

31. 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

32. Stapedius reflex
 Nerve to stapedius muscle test
 Impedance 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

33. Management
 Extracranial etiology
 Trauma
 Iatrogenic
 Neoplasm
 Intratemporal etiology
 Fracture
 Iatrogenic
 Neoplasm
 Idiopathic (Bell’s
palsy)
 Infection

34. Idiopathic facial palsy (Bell's Palsy)
 Most common cause of facial paralysis (>50% of case)
 Most age 25-30 yrs.
 Male : Female = 1 : 1
 Left side : Right side = 1 : 1
 Unilateral > bilateral
 Increase risk in
 pregnancy 3.3 times
 DM 4.5 times
 Recurrent rate 10%
 60% have previous URI

35. Etiology
 Unknown
 Microcirculatory failure of vasa nervorum
 Viral infection (HSV)
 Ischemic neuropathy
 Autoimmune reaction
 Entrapment theory

36. Diagnosis
 By exclusion
 Criteria :
 Paralysis or paresis of all muscle groups of
one side of the face
 Sudden onset
 Absence of signs of CNS disease
 Absence of signs of ear or CPA disease

37. Medical treatment
 Corticosteroids :
 prednisolone 1 mg/kg/day 7-10 days
 Corticosteroids combine with antiviral
drug is better
 Acyclovir 400 mg 5 times/day
 Famciclovir and valacyclovir 500 mg bid

38. Surgical treatment
 Facial nerve decompression
 Indication
 Completely paralysis
 ENOG less than 10% in 2 weeks
 Appropriate time for surgery is 2-3 weeks
after paralysis

39. Herpes Zoster Oticus
(Ramsay Hunt Syndrome)
 3rd most common of peripheral facial paralysis
(10%)
 Aged > 60 yrs. or low immune (low CMIR)
 Virus travels to the dorsal root extramedullary
cranial nerve ganglion
 Infected of HZV at auricular, external canal or
face
 Prodromal symptoms very similar to those seen in
Bell's palsy
 but usually more severe

40. Herpes Zoster Oticus
(Ramsay Hunt Syndrome)
 Symptoms include severe otalgia, facial paralysis,
facial numbness, and a vesicular eruption on the
concha, external auditory canal, and palate
 Facial paralysis + hearing loss + vertigo 
“canal paralysis”
 Pathophysiology & treatment liked in Bell ’s
palsy

41. Temporal bone fractures
 Longitudinal fracture
 Transverse fracture
 Mixed fracture

42. Temporal bone fractures
 Signs
 bleeding from the external canal
 hemotympanum
 step-deformity of the osseous canal
 conductive hearing loss (longitudinal fracture)
 sensorineural hearing loss (transverse fracture)
 CSF otorrhea
 facial nerve involvement (20% of longitudinal
fractures and 50% of transverse fractures)

43. Longitudinal VS Transverse
Type of
injury
Longitudinal Transverse
Incidence 70-90% 10-20%
Site of injury Temporal ,
Parietal area
Occipital ,
Frontal area

44. Prognosis
 Immediate onset paralysis : poor prognosis
 Delayed onset paralysis : good prognosis
 All case of paralysis  electrical testing

45. Treatment
 Surgery is treatment of choice
 Indications for facial nerve exploration
 incomplete paralysis
 iatrogenic paralysis
 Contraindications : any case have no
poor prognostic factors

46. Complications
 Complications of facial nerve
decompression
 dural tears
 conductive or sensorineural hearing loss
 vestibular function loss
 persistent CSF leaks
 meningitis
 injury to the anterior inferior cerebellar artery
(AICA) or its branches