nerve injuries- facial palsy

1. NERVE INJURIES
BHANU PRIYA U
Reg.no:120020750

2. CONTENTS
 INTRODUCTION
 NEURON
 PHYSIOLOGY OF NERVE INJURY
 CLASSIFICATION OF DISORDERS OF NERVE
 MANAGEMENT

3. INTRODUCTION
 Neuron is an exitable tissue
neuron
processes
Axons dendrites
Cell body

4. Dendrites
Myelin sheath
Schwann cell Nucleus of Schwann cell
Axon
Nodes of Ranvier
Terminal dendrites

6. PHYSIOLOGY OF NERVE INJURY
When an
axon is
injured
in cell body
proximal and
distal to site
of injury
Biochemical
& histological
changes
occur

7. CLASSIFICATION
1.TRAUMATIC INJURIES
 Neurapraxia
 Axonotmesis
 Neurotmesis
 Traumatic neuroma
2. INFLAMMATION
 Neuritis
3. NEURALGIAS
 Trigeminal neuralgia
 Bells palsy
 Glossopharyngeal neuralgia
 Sphenopalatine neuralgia

8. 4. SPECEFIC TYPE OF INJURIES
 Injection injuries
 Irradiation
 Compression neuropathies
5. TUMORS
 Benign
 malignant

9. SEDDON’S CLASSIFICATION
(1943)
Depending on three main types of nerve fibre injury & based on
continuity of nerve
 NEURAPRAXIA
 AXONOTMESIS
 NEUROTMESIS

10. SUNDERLAND’S CLASSIFICATION
First Degree- Neurapraxia
Second Degree- Axonotmesis
Third Degree- Endoneurotmesis
Fourth Degree- Perineurotmesis
Fifth Degree- Neurotmesis

12. First degree/ neurapraxia
 Localised conduction block in the nerve
 Nerve fibres respond to electrical stimuli proximal and
distal to the lesion
 No conduction across the injured segment
 Axonal continuity is preserved
 No wallerian degeneration
 Usually complete recovery
 CAUSES:- biochemical lesion caused by concussion /
shock like injuries to nerve
Compression/ blows to the nerve

13. Second degree/ axonotmesis
 Disruption of axon into proximal and distal portion
 interrupted axoplasmic flow
 Loss of relative continuity of axon and its covering of
myelin but preservation of connective tissue
 Wallerian degeneration occur within 24 hrs in distal
portion & a slight degree in proximal portion
 Intact connective tissue
 Axon may regenerate at rate of 1mm/day
 Potential for complete recovery

14. Third degree/ endoneurotmesis
Endoneurium and axon are injured
Perineurium remains intact
Wallerian degeneration occurs
Axons may regenerate but may be blocked by scar
tissue――――› partial re-innervation
Incomplete recovery

15. Fourth degree/ perineurotmesis
Only epineurium remains intact
Axon, endoneurium & perineurium are disrupted
Wallerian degeneration occur
Greater chance of abberent degeneration
Incomplete recovery

16. Fifth degree/ neurotmesis
 Complete disruption of nerval continuity
 Most severe & occur on severe contusion, stretch &
lacerations
 Not only axon but also connective tissue lose their
continuity
 Extreme degree is transection- complete loss of
sensory,motor and autonomic function
 Without carefull repair, no chance of regeneration and
recovery
 Axonal sprouts may escape into nerve sheaths and
produce painful neuromas

17. TRAUMATIC NEUROMA/
AMPUTATION NEUROMA
 Reaction of peripheral nerves to local injury
 Painful submucosal bump
Cutting of a peripheral nerve
during surgical/ traumatic episodes
During subsequent regeneration
Axons canot find their way into
severed nerve sheath
Forms a painful disorganized mass
in area of injury

18. H/P
 Presence of a jumble of small peripheral
nerve fibre
T/T
Surgical excision

19. NEURITIS
 Inflammation of a peripheral
nerve accompanied by
degenerative changes in nervous
tissue
 TYPES- localized and
multiple/polyneuritis
 polyneuritis – affects many
peripheral nerves symmetrically
at the same time

20. AETIOLOGY-
1. LOCALIZED
 Exposure to cold
 Blows & wounds to nerve
 Stretching of nerve
 Extension of inflammation
 Vascular reasons- occlusion of blood
vessel/ hemorrhage

21. GENERALIZED
 Infection
 Toxic – metallic/alchoholic
 Metabolic- vitamin deficiencies,pernicious
anemia
 General disorders- gout, rheumatism,
carcinoma
 Endemic disease- beri beri
 Autoimmune disease- SLE
 Diabetic mellitus

22. SIGNS AND SYMPTOMS
 Pain of boring character along the
course of the nerve
 Redness/ oedema along the course
of nerve
 Muscle pain , numbness,
impairement of tactile sensation
 Finally muscular atrophy &
degenerative changes

23. FACIAL NERVE INJURY
 FACIAL PALSY/ BELL’S PALSY
CLINICAL FEATURES
 Characteristic features- impaired blinking,
sagging cheek, flattening of nasolabial
crease
 Alterd lacrimal secretion
 Altered salivary secretion
 Impairement of taste perception
 Weakness of all facial muscles
 Impaired eye closure

24. AETIOLOGY OF FACIAL PALSY
1. Trauma
2. Herpes zoster oticus/ ramsay hunt syndrome
3. Otitis media
4. Tumours
5. Melkerson-Rosenthal syndrome
6. Congenital facial paralysis
7. Other causes- sarcoidosis, lyme disease
8. Bells palsy

25. DIAGONOSIS
Basic functions are examined
1. Raising the eyebrows to test frontalis
corrugator
2. Tightly closing the eyes for orbicularis
oculi
3. Ask pt. to grin to examine retractor
muscles on angle of mouth
4. Taste may also be tested

26. Assesing the degree of voluntary involvement
House classification
Grade Degree Description
I normal Normal facial movements
II slight Mild deformity, slight assymetry
III moderate Obivious Facial weakness, forhead motion
present, good eye closure, asymmetry, bells
palsy
IV moderately Obivious facial weakness, no forhead motion
V severe Very obivious facial paralysis, some tone
present,cannot close eye
VI total Complete facial paralysis, absent tone

27. MANAGEMENT
MEDICAL MANAGEMENT
 EYE CARE- to prevent exposure keratitis
lacrilube ointment in eye
tapping of eyelids during sleep
Use of a moisture chamber

28.  SURGICAL MANAGEMENT
2 types- primary & secondary
1. PRIMARY MANAGEMENT
Neurorrhaphy
 Indication- sharp precise lacerations of facial
nerve
 Technique- by skilled microsurgeon
 Identification of nerve
 Suturing of nerve- identified nerves are
carefully trimmed & direct simple perineural
sutures are used
 Nylone/ prolene sutures are used
 Surgeons knot with 2 square throws are
adequate

29. GRAFT NEURORRHAPHY
 Indications-avulsive type of injuries
 Common donor site-greater auricular nerve, sural
nerve, antebrachial cutaneous nerve
GREATER AURICULAR NERVE
 Identified in relation to external jugular vein
 Surface marking- a perpendicular at the midpoint
of a line drawn from mastoid to angle of
mandible.
 TECHNIQUE: elevation of platysma
 6-8 cm of nerve length
 Nerve is isolated posterior to jugular vein and
dissected to its entrance in to parotid

30. SURAL NERVE
 Branch of tibial nerve in popliteal fossa
 Supplies skin on the lower half of back of leg and
whole of the lateral border of foot up to tip of
little toe
 ADVANTAGE-abundant length up to 40cm,diameter
approx. to most of cranial nerve, used in multiple
facial nerve defects
ANTEBRACHIAL CUTANEOUS NERVE
 Originates from brachial plexus
 Located adjacent to basilar vein near antecubital
fossa
 Most useful for facial nerve reconstruction.

31. CROSS-FACIAL NERVE
GRAFTING
 Use of normal facial nerve on the uninjured side.
 Buccal branch of normal facial nerve is sacrificed

32. NERVE TRANSPOSITION
 Used in 2 situations.
1. When there is isolated segmental injury to a
crucial branch of facial nerve.
In such cases less critical segment of facial
nerve(frontal,cervical) is accomplished.
2. When extreme proximal facial nerve is injured.
Hypoglossal nerve is transposed and sutured to trunk
of distal facial nerve
Drawback is mass movement of face

33. Secondary management
SURGICAL MANAGEMENT
Surgical technique I- temporalis lengthening
with fascia lata
Surgical technique II- temporalis lengthening
without fascia lata

34. STATIC SUSPENSION
 Oldest methods reconstruct nasolabial
fold and labial commisure
 Fascia lata is used
NEUROMUSCULAR TRANSFER
 Gracilis muscle
FACIAL REANIMATION
 Using hypoglossal/ contralateral facial
nerve/ surgical redirection of accessory
cranial nerve into the degenerate 7th
nerve which help in restoring some facial
muscle function

35. NEURALGIA
TRIGEMINAL NEURALGIA
 Facial pain syndrome characterized by sharp,
lancinating pain in the face
 Etiology- tumors , vascular defects, compression by
superior cerebellar artery
 Clinical features-
1. Medical care
2. Surgical care- a) peripheral procedures
b) ganglion procedures
c) open operation
d) central procedures

36. MEDICAL CARE
 Carbamazepine( tegretol)
 Phenytoin
 Baclofen
 Clonazepam
 Amitryptaline
 Gabapentin
 lamotrigine

37. SURGICAL MANAGEMENT
1. Peripheral procedures-
cryotherapy, laser, neurectomy
2. Ganglion procedures-
thermocoagulation, glycerol
injection, ballon
compression,radio surgery
3. Open operations- microvascular
decompression, trigeminal root
resection
4. Central procedures- tractotomy

38. Anaesthesia dolorosa
 Following injury to trigeminal nerve ,painful area
of numbness may develop
 Severe, constant, Burning, gnawing or stinging
type of pain
 t/t:- often ineffective
medications often not relieve pain
Surgical methods have limited success

39. Geniculate neuralgia
 Nervous intermedius neuralgia
 Severe pain deep in the ear
 Sharp shooting/gnawing type of pain
 May spread to ear canal, outer ear, mastoid
or eye regions
 T/t:- not with medications
Surgical- microvascular decompression of 5th 9th
and 10th cranial nerve

40. Sphenopalatine/ sludgers
neuralgia
 Unilateral headache behind the eyes with
pain in the upper jaw or soft palate
 Assosiated with nasal/ sinus congestion,
swelling/redness of face
 Longer duration of pain with inflamed
nasal mucosa on involved side

41. PARATRIGEMINAL NEURALGIA
OF RAEDER
 Headache in upper face associated with
eye and skin changes
 Intense / throbbing pain

42. Reference
 TEXTBOOK OF ORAL AND MAXILLOFACIAL SURGERY- S M
BALAJI
 TEXTBOOK OF ORAL AND MAXILLOFACIAL SURGERY-
NEELIMA ANIL MALIK