BELL'S PALSY IS AN IDIOPATHIC LMN TYPE FACIAL PALSY..THE SEMINAR TELLS YOU OF COURSE OF NERVE..FACIAL MUSCLES THEIR ACTION..HOW TO EXAMINE..THE SEQUELAE OF FACIAL PALSY...LOOK AT IT..
Discussion of facial nerve palsy including motor anatomy of the facial nerve, symptoms of Bell's Palsy, the differential diagnosis and treatment strategies
BELL'S PALSY IS AN IDIOPATHIC LMN TYPE FACIAL PALSY..THE SEMINAR TELLS YOU OF COURSE OF NERVE..FACIAL MUSCLES THEIR ACTION..HOW TO EXAMINE..THE SEQUELAE OF FACIAL PALSY...LOOK AT IT..
Discussion of facial nerve palsy including motor anatomy of the facial nerve, symptoms of Bell's Palsy, the differential diagnosis and treatment strategies
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
HOT NEW PRODUCT! BIG SALES FAST SHIPPING NOW FROM CHINA!! EU KU DB BK substit...GL Anaacs
Contact us if you are interested:
Email / Skype : kefaya1771@gmail.com
Threema: PXHY5PDH
New BATCH Ku !!! MUCH IN DEMAND FAST SALE EVERY BATCH HAPPY GOOD EFFECT BIG BATCH !
Contact me on Threema or skype to start big business!!
Hot-sale products:
NEW HOT EUTYLONE WHITE CRYSTAL!!
5cl-adba precursor (semi finished )
5cl-adba raw materials
ADBB precursor (semi finished )
ADBB raw materials
APVP powder
5fadb/4f-adb
Jwh018 / Jwh210
Eutylone crystal
Protonitazene (hydrochloride) CAS: 119276-01-6
Flubrotizolam CAS: 57801-95-3
Metonitazene CAS: 14680-51-4
Payment terms: Western Union,MoneyGram,Bitcoin or USDT.
Deliver Time: Usually 7-15days
Shipping method: FedEx, TNT, DHL,UPS etc.Our deliveries are 100% safe, fast, reliable and discreet.
Samples will be sent for your evaluation!If you are interested in, please contact me, let's talk details.
We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
Follow us on: Pinterest
Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
7. Histology of facial nerve
Each nerve fibre :
nerve cell body, axon :
surrounded by myelin
secreted by schwann
cells
Endoneurium : to form
tubule
Multiple tubules :
perineurium
Epineurium : nerve
sheath
8. The facial nerve gets it’s blood supply from 4 vessels:
Anterior inferior cerebellar artery – at the
cerebellopontine angle
Labyrinthine artery (branch of anterior inferior
cerebellar artery) – within internal acoustic meatus
Superficial petrosal artery (branch of middle
meningeal artery) – geniculate ganglion and nearby
parts
9. Stylomastoid artery
(branch of posterior auricular artery) –
mastoid segment
Posterior auricular artery supplies the facial
nerve at & distal to stylomastoid foramen
Venous drainage parallels the arterial blood
supply
10. Degrees of nerve injury
Neuropraxia : no
wallerian degenration
Axonotmesis : distal
wallerian degenration
occurs, intact
perineurium, total
paralysis
Neurotmesis :
wallerian degenration
occurs
11. Sunderland classification
1°: Partial block: Neuropraxia
2°: Loss of axons, endoneurial tubes remain intact:
axonotmesis
3°: Injury to the endoneurium: neurotemesis
4°: Injury to the perineurium in addition to above: partial
transection
5°: Injury to the epineurium in addition to above:
complete transection
The first three degrees are seen in viral and
inflammatory disorders while 4th and 5th are seen in
surgical or accidental trauma
12.
13. CAUSES OF FACIAL PARALYSIS
CENTRAL
Brain
abcess
Pontine
Gliomas
Poliomyeliti
s
Multiple
sclerosis
GB
syndrome
INTRACRA
NIAL
Acoustic
neuroma
meningioma
congenital
cholesteato
ma
metastatic
carcinoma
meningitis.
INTRATEMPORAL
A. Idiopathic Bell’s palsy
Melkersson’s syndrome
B. Infections
ASOM,CSOM, Herpes
zoster oticus, malignant
otitis externa
C. Trauma –
Mastoidectomy,
Stapedectomy, #
temporal bone
D. NEOPLASMS
Malignancies of external
and middle ear
glomus jugulare tumour
facial nerve neuroma
metastasis to temporal
bone, cholesteatoma, VII
nerve tumour,
meningioma,
schwannoma
EXTRACRAN
IAL
Malignancy
of parotid, sx
of parotid,
accidental
injury in
parotid
region.
Neonatal
facial injury
SYSTEMIC
DISEASES
DM,
Hypothyroidism
, uraemia,PAN,
wegener’s
granulomatosis
,
sarcoidosis,lepr
osy, leukemia,
demyelinating
disease.
14. Altered function of facial nerve following
injury
SYNKINESIS- Abnormal synchronization movement
occuring with voluntary and reflex activity of muscle
which normally do not contract together.
CROCODILE TEARS- Increased unilateral
lacrimation on involved side associated with eating.
STAPEDIUS TENDON CONTRACTION –
Hyperkinetic syndrome with faulty facial regeneration
causes fullness and roaring in ear.
FACIAL MYOKYNIA – Continuous fine fibrillary
movement of facial muscles giving “bag of worms”
facial appearance.
19. SCHIRMER TEST- decrease in lacrimation of 75%
or more as compared to normal side. Or < 10mm for
both sides at 5 min.
STAPEDIAL REFLEX TESTING - if absent , site of
lesion between geniculate ganglion and stapedius
muscle. If present then site of lesion is distal to
stapedius muscle.
TASTE TESTING – conc. Sweet, salt, sour and bitter
solution tested along lateral margin of anterior 2/3 of
tongue towards tip / electrogustometry ( EGM )
SUBMANDIBULAR GLAND FLOW- compared by
sialometry using 6% citric acid.
TESTING FACIAL MOVEMENT
20.
21. ELECTRICAL TESTING
Nerve Excitability Test - minimal current necessary to
stimulate muscle movement when applied to a branch of
facial nerve. A difference of 3.5mA or greater between
two sides is thought to be significant.
Maximum Stimulation Test – strength and duration of
stimulation is gradually increased from 1mA to 5mA.
Useless <72 hrs.
ELECTRONEURONOGRAPHY - action potentials
developed in the muscles by stimulation of the nerve is
measured and expressed as % of degeneration
compared to normal side. Surgical intervention in case of
immediate paralysis with> 90% degeneration.No use <
72 hrs.
22. NERVE EXCITABILITY TEST (NET)
Compares
transcutaneous current
threshold required to
elicit minimal muscle
contraction between two
sides
A difference of 3.5
milliamperes (mA) or
more in thresholds
between the two sides a
reliable indicator of
progressive
degeneration :indicator
for surgical
decompression
If the paralysis becomes
total, the test can
determine whether a
pure conduction block
exists or whether
degeneration is
occurring, as indicated
by progressive loss of
excitability.
23. MAXIMAL STIMULATION TEST (MST)
Instead of measuring
threshold, however,
maximal stimuli (current
levels at which the
greatest amplitude of
facial movement is seen)
is employed.
degree of facial
contraction is subjectively
assessed as either equal,
mildly decreased,
markedly decreased, or
without response
compared with that on the
normal side.
Movements on the
paralyzed side are
subjectively expressed as
a percentage (0%, 25%,
50%, 75%, 100%) of the
movement on the normal
side.
Symmetric response
within first ten days –
complete recovery in >
90%
No response within first
ten days – incomplete
recovery with significant
sequelae
24. ELECTROMYOGRAPHY
The recording of
spontaneous and voluntary
muscle potentials by needles
introduced into the muscle is
called electromyography
(EMG).
Records motor unit
potentials of the orbicularis
oculi & orbicularis oris
muscle during rest &
voluntary contraction
In a normal resting muscle
biphasic / triphasic potentials
are seen every 30-50msec.
25. EMG can be used to determine:-
1.If a nerve in question is in fact in
continuity(volitional activity recorded)
2.Evidence of degenration ( fibrillation after 10-14
days)
3.If there are early sign of reinnervation
(polyphasic innervation potentials after 4-6 weeks)
26. Fibrillation potentials typically arises 2-3 weeks
following injury
With regeneration of nerve after injury, polyphasic
reinnervation potential replaces fibrillation
potential
Reinnervation potentials may precede clinical
signs of recovery by 6-12 weeks
27. Polyphasic potential indicate regenrative process &
surgical intervention is therefore not indicated
Fibrillation indicate lower motor neuron denervation
but viable motor end plates, so surgical intervention
needed(to achieve nerve continuity)
Electrical silence indicates atrophy of motor end
plates & need for muscle transfer procedure
28. EVOKED ELECTROMYOGRAPHY
(EEMG) OR EVOKED
ELECTRONEURONOGRAPHY (EnoG)
Records compound
muscle action potential
(CMAP) with surface
electrodes placed
transcutaneously in the
nasolabial fold
(response) and
stylomastoid foramen
(stimulus)
29. EVOKED ELECTROMYOGRAPHY
(EEMG) OR EVOKED
ELECTRONEURONOGRAPHY (EnoG)
Waveform responses are analyzed to compare peak-to-
peak amplitudes between normal and uninvolved sides
where the peak amplitude is proportional to the number
of intact axons.
Most valuable prognostic indicator---Its main indicaion
acute onset complete facial paralysis
This method offers the potential advantage of an
objective registration of electrically evoked responses,
and the amplitude of response of the paralyzed side (in
mV) can be expressed as a precise percentage of the
normal side's response.
30. ELECTRONEURONOGRAPHY (EnoG)
• )
Response <10% of normal in first 3 weeks-poor prognosis
Response >90% of normal within 3 weeks of onset-
80-100% probability of recovery
Testing every other day
Not useful until 4th day of paralysis as it takes about 3 days
for degeneration to reach completion
Also of less value after three weeks bcoz of nerve fibre
desynchronization
Advantages: Reliable
Disadvantages:
Uncomfortable
Cost
Test-retest variability due to position of electrodes
31. Limitation of electophysiological
testing
Electric impulse can stimulate only normal/
neuropraxic fibres and can’t distinguish b/w
axonotemesis or neurotemesis
Provides no useful information in cases of
incomplete facial paralysis
It fails to provide information on the immediate
post paralysis period( first 72 hours)
32. Imaging
Magnetic resonance imaging (MRI) with intravenous
gadolinium contrast has revolutionized tumor detection in
the cerebellopontine angle and temporal bone and is
currently the study of choice when a facial nerve tumor is
suspected (e.g., in a case of slowly progressive or
longstanding weakness)
However, enhancement also occurs in most cases of
Bell’s palsy and herpes zoster opticus, usually in the
perigeniculate portions of the nerve. This enhancement
may persist for more than 1 year after clinical recovery;
can be distinguished from neoplasm by its linear,
unenlarged appearance; and has no apparent prognostic
significance.
33. Computed tomography (CT) is valuable for surgical
planning in cholesteatomas and temporal bone
trauma involving facial nerve paralysis but probably
is less useful than MRI in the investigation of
atypical idiopathic paralysis.
Unfortunately, even MRI fails to detect a substantial
number of malignant parotid tumors.
MRI shows the greatest utility in predicting location
and depth of parotid gland tumors, but even in this
capacity it is no better than simple manual
palpation alone.
34. SIGN DIFFERENTIATING SUPRANUCLEAR
FROM INFRANUCLEAR LESIONS
SUPRANUCLEAR INFRANUCLEAR
Forehead intact bilaterally
FND, Hemiplegia on side
of facial palsy
Ataxia
Reflexes intact
Tone maintained
Drooping corner of mouth
Slight flattening of
nasolabial fold.
No muscle atrophy/
fasciculation
Total facial palsy
No FND
No hemiplegia
No ataxia
No reflexes
Flaccid
Not an isolated finding
Not an isolated finding
Muscle atrophy /
fasciculations present.
35.
36. BELL’S PALSY
First described more than a
century ago by Sir Charles Bell
Bell palsy is certainly the most
common cause of facial paralysis
worldwide
37. U/l spontaneous idiopathic lower motor neuron facial
palsy
Incidence of Bell’s palsy is 20 to 30 patients per 100,000
population
The incidence is greater in patients
older than 65 years and lower in children younger than
age 13.
The male-to-female ratio for Bell’s palsy is approximately
equal,
except for a predominance in women younger than 20
years of age and a slight predominance in men older
than 40
The left and right sides of the face are equally involved
38. 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 disease
39. 30% of patients will have incomplete paralysis on
presentation
70% will have a complete paralysis.
Bilateral paralysis occurs in 0.3%
Have a history of previous paralysis.
A family history of Bell’s palsy can be elicited in
8% of patients
40. Pathophysiology
Main cause of Bell's
palsy is latent
herpes viruses
(herpes simplex virus
type 1 and herpes
zoster virus), which
are reactivated from
cranial nerve ganglia
Edema of nerve within
inelastic fallopian
canal
Recovery begins by 3
weeks, full recovery
by 6months
70 % : 15 % : 15%
41. most important prognostic factor is whether the paralysis
is incomplete or complete.
The prognosis for affected persons in whom complete
facial paralysis never develops is excellent: 95% to 100%
factors associated with poor outcome include
hyperacusis; decreased hearing; age older than 60
years; diabetes mellitus; hypertension;and severe aural,
anterior facial, or radicular pain
42.
43. Ramsay Hunt Syndrome
Caused by reactivation varicella zoster virus (herpes
virus type 3)
Facial paralysis + hearing loss +/- vertigo
Herpes zoster oticus
Two-thirds of patients have rash around ear
Other cranial nerves, particularly trigeminal nerves (5th
CN) often involved
Worse prognosis than Bell’s (complete recovery: 50%)
Important cause of facial paralysis in children
6-15 years old
44. The timing of the appearance of the vestibular eruption
may have prognostic significance. In most cases, eruption
and paralysis occur simultaneously.
In approximately 25% of cases, the eruption precedes the
paralysis; these patients have a higher likelihood of
recovery.
Patients with Ramsay Hunt syndrome also are more likely
than patients with Bell’s palsy to have associated cranial
nerve symptoms, including hyperacusis, hearing loss, and
pain.
In approximately 10% of patients, the vesicular rash
appears well after the initial facial paralysis,
many patients demonstrate a rise in antibody to VZV
without ever exhibiting cutaneous or mucous membrane
vesicles—so-called Ramsay Hunt sine herpete.
45.
46. Severe ocular complications can occur with
herpes zoster ophthalmicus.
These complications include uveitis,
keratoconjunctivitis, optic neuritis, and glaucoma
and are almost always associated with
involvement of the ophthalmic division of the
trigeminal nerve
47. Management of patients with herpes zoster, including
cephalic zoster, consists of systemic corticosteroids.
A specific benefit of corticosteroid therapy is a
reduction in postherpetic neuralgia. The usefulness of
corticosteroids in fostering recovery from the facial
paralysis is controversial; however, early institution of
corticosteroids seems to
relieve acute pain, reduce vertigo, and decrease the
incidence of postherpetic neuralgia
The antiviral agent acyclovir also is recommended to
treat herpes zoster facial
48. Congenital Facial Paralysis
The incidence of facial paralysis in newborns has been
estimated at 0.23% of live births.
Birth trauma usually causes isolated facial paralysis and
other signs of injury, including facial swelling,
ecchymosis, and hemotympanum. Abnormalities of other
cranial nerves or abnormalities on brainstem audiometry
(prolongation of the I to III or I to V interval) suggest that
the facial paralysis is congenital and not traumatic.
Of facial paralysis cases in infants, 78% are related to
birth trauma.
These cases are equally divided between forceps
deliveries and vaginal deliveries plus cesarean sections,
suggesting that intrauterine facial nerve injury can occur
from pressure on the infant’s face by the sacral
prominence during birth
49. Möbius’ syndrome represents a broad spectrum of
clinical and pathologic findings ranging from isolated
unilateral facial paralysis (usually associated with
sixth cranial nerve paralysis) to bilateral absence of
facial and abducens nerve function.
Multiple other cranial nerves,including the
glossopharyngeal, vagus, hypoglossal, and other
extraocular motor nerves, also may be affected
50. Infectious causes
Acute facial paralysis may result from bacterial or
tuberculous infection of middle ear, mastoid &
necrotizing otitis externa
Incidence of facial paralysis with otitis media:
0.16%
◦ Infection extends via bone dehiscences to nerve in
fallopian canal leading to swelling, compression &
eventually vascular compromise & ischemia
Immune compromised patients are at risk for
pseudomona infection
Poor prognosis (complete recovery is < 50%)
51. Neoplasms
27% of patients with tumors involving the facial
nerve develop acute facial paralysis
Most common causes: schwannomas,
hemangiomas (usually near geniculate ganglion)
& perineural spread such as with head and neck
carcinoma, lymphoma & leukemia, congenital
cholesteatoma
Other neoplasms can also involve the facial
nerve
◦ Adults: metatstatic disease, glomus tumors,
vestibular schwannomas & meningiomas
◦ Children: eosinophilic granuloma & sarcomas
52. Slowly progressive facial paralysis
Early diagnosis : high degree of suspicion
h/o recurrent palsy, involvement of other cranial
nerves.
CT and MRI
Tumout resection with grafting
53. Recurrent facial palsy: seen in
Bell’s palsy,
Melkersson’s syndrome,
diabetes,
sarcoidosis
tumuors
54. Melkersson-Rosenthal Syndrome
Acute episodes of facial paralysis
Facial swelling
Fissured tongue
Very rare
Familial but sporadic
Usually begins in adolescence
Leads to facial disfigurement
No definite therapy
56. Traumatic facial nerve palsy
Second most common cause of FN
paralysis
- Represents 15% of all cases of FN
paralysis
- Most common cause of traumatic facial
nerve injury is temporal bone fracture
59. Iatrogenic
– Surgical
• Most common overall surgery with FN injury is parotidectomy
• Most common otologic procedures with FN paralysis
– Mastoidectomy – 55% of surgical related FN
paralysis
– Tympanoplasty – 14%
– Mechanism - direct mechanical injury or heat
generated from drilling
– Most common area of injury – distal tympanic
segment including the 2nd genu, followed by
mastoid segment
• Unrecognized injury during surgery in nearly 80% of cases
60. SURGICAL LANDMARKS OF FACIAL
NERVE
FOR MIDDLE EAR AND MASTOID SURGERY
Processus cochleariformis
Oval window and horizontal canal
Short process of incus
Pyramid
Tympanomastoid suture
Digastric ridge
61. For parotid surgery
Cartilaginous pointer
of conley
Tympanomastoid
suture
Posterior belly of
digastric
Styloid process
62.
63. Surgical management
A. Facial nerve decompression
B. Neurorrhaphy(nerve repair)
1.direct end to end anastomosis
2. interposition cable grafting
C. Nerve transposition: hypoglossal-facial
D. Muscle transposition: temporalis, masseter
E. Micro-neuro-vascular muscle flap
F. Static procedure: eyelid implant, facial sling
64. Intratemporal Approaches to
Decompression
• Nerve may be injured along multiple segments
– localize injured site pre-operatively
– Full exposure of the nerve from IAC to the stylomastoid
foramen if can’t localize
• Approach to full exposure is based on patient’s auditory
and vestibular status
– Intact - Transmastoid/Middle cranial fossa approach
– Absent – Transmastoid/Translabyrinthine approach
66. Retrolabyrinthine and retrosigmoid
approach
Advantages Complications
Access to FN in CP
angle without sacrificing
the inner ear function
No cerebellar
compression
AICA and other vessels
easily manipulated
Visualization of nerve
hampered by location
of 8th nerve
Increased risk of
hearing loss during
separation from 8th
nerve
Csf leak
Vascular
complications
69. Advantages Complications
the only method that
exposes the entire
internal auditory canal
and labyrinthine
segment with
preservation of hearing
most commonly used
for decompression of
the facial nerve in Bell’s
palsy and with
longitudinal temporal
bone fractures.
Dural elevation can be
difficult
Persistent CSF leakage
Conductive and
sensorineural hearing
losses can result
70. Transmastoid approach
Advantages Complications
excellent exposure of the
mastoid and tympanic
segments of the facial
nerve
used in conjunction with
middle fossa and
retrolabyrinthine
approaches if total facial
nerve exposure is
required and inner ear
function is to be
preserved
limited access to the
geniculate ganglion and
the inability to reach the
labyrinthine segment.
Conductive or
sensorineural hearing
loss also can be a
complication if the incus
is removed or touched
by a rotating burr during
the procedure.
71.
72. Translabyrinthine approach
Advantages Complications
The translabyrinthine
exposure of the facial nerve
is used primarily when the
cochlear and vestibular
functions have been lost
preoperatively.
The greatest advantage with
this technique of facial nerve
exposure is the ability to
access the entire nerve
using one approach
Hearing and balance
function must be
sacrificed for total
exposure of the nerve
CSF leakage and
infection are the greatest
risks
73.
74. Facial Reanimation
Facial reanimation is a family of different
surgical techniques to make one's
paralyzed face move more normally.
74
75. Assessment and Planning
Cause of facial paralysis
Functional deficit/extent of paralysis
Time course/duration of paralysis
Likelihood of recovery
Other cranial nerve deficits
Patient’s life expectancy
Patient’s needs/expectations
76. Primary Nerve Repair
End-to-end
anastomosis
preferred
Can be performed
with defect < 17 mm
Extratemporal repair
performed < 72 hrs of
injury
Most common
methods
Group fascicular
repair
Epineural repair
Group fascicular repair
77. Primary Nerve Repair
Severed ends of nerve
exposed
Devitalized tissue/debris
removed with fine scalpel
Small bites of epineurium
Epineural sheath
approximated with 9-0
nonabsorbable suture
Epineural repair
recommended for injury
proximal to pes anserinus
and intratemporal
Horizontal segment rarely
accessible to suture repair Epineural repair technique
78. Nerve Repair
• Recovery of function begins around 4-6 months and
can last up to 2 years following repair
• Nerve regrowth occurs at 1mm/day
• Goal is tension free, healthy anastomosis
• Rule is to repair earlier than later -
– After 12-18 months, muscle reinnervation becomes less
efficient even with good neural anastomosis
– Some authors have reported improvement with repairs as
far out as 18-36 months
• 2 weeks following injury -> collagen and scar tissue
replace axons and myelin
– Nerve endings must be excised prior to anastomosis for
this reason if this far out
79. The clinical uses of interposition grafts
(1) radical parotidectomy with nerve sacrifice;
(2) temporal bone resection;
(3) traumatic avulsions;
(4) cerebellopontine angle tumor resection;
(5) any other clinical situation in which viable
proximal nerve can be sutured and distal
elements of facial nerve can be identified
80. Interposition Grafting
Cable grafts
Used when defect > 17mm; nerve cannot be
reapproximated w/o tension
Most common
Greater Auricular Nerve
Sensory nerves from superficial cervical plexus
Sural nerve
Medial antebrachial cutaneous nerve
81. Useful features
Proximity to facial
nerve
Cross-sectional
area (~equal)
Limited morbidity
Limitations
Reconstruction of
long defects and/or
branching nerve
gaps
maximum of 10 cm
82. Pros:
Length (70cm)
Accessibility
Low morbidity
associated with
sacrifice
Two team approach
Reduced surgical time
Cons:
Variable caliber
Often too large
Difficult to make
graft approximation
Unsightly scar
83. MBCN
Important landmarks:
Medial epicondyle of
humerus
Biceps tendon
Basilic and medial
cubital veins
Fascial plane
separating bicep from
tricep
Upper extremity can be
prepped from axilla to
wrist or continuous with
the head/neck.
Nerve diameter and
branching pattern are
similar to those of the
facial nerve, and donor
site morbidity is minimal
with nerve harvest
84. Surgical Technique
For the surgical technique of neurorrhaphy, interrupted sutures using
9-0 or 10-0 monofilament nylon are preferred.
Both ends of the nerve graft and the proximal and distal stumps should be
transected cleanly with a fresh sterile blade.
Epineural sutures
Approximation of the nerve ends using an acrylic glue has been
described : Histacryl or cyano-butyl-acrylate
The nerve graft should lie in the healthiest possible bed of supporting tissue
Suction drainage systems should be placed away from any portions of the
nerve graft.
85. Grafting and Nerve Transfer -
Overview
Approach is based on availability of proximal nerve ending
Performed for defects > 17mm
Results in partial or complete loss of donor nerve function
Best functional results are obtained with cable grafting when a
segment of the facial n. is disrupted
Also recommended if there is tension at the anastomotic site of
a primary nerve repair
Graft should be aprox. 25% longer than needed to allow for
a tension free anastomosis
86. Facial nerve transposition
Reinnervation by
connecting an intact
proximal facial nerve
to the distal ipsilateral
facial nerve
87. Hypoglossal-Facial
Technique modification aka partial XII-VII transfer
Donor nerve harvested
One end of donor nerve is sutured to severed main
trunk of CN VII; other end hooked up to proximal
segment of partially severed CN XII
The procedure has been modified by only partially
sectioning the hypoglossal nerve and interposing, by
end to-side anastomoses,by a greater auricular nerve
graft between the hypoglossal and facial nerves.
Since the hypoglossal nerve is transected only
halfway, tongue function can be preserved.
Limits tongue dysfunction and atrophy
88. Cross-facial Nerve Grafting
Contralateral CN VII used to reinnervate paralyzed
side using a nerve graft
◦ Sural nerve often employed
◦ ~25-30cm of graft needed
Restitution of smile and eye blinking when
successful
Disadvantage
◦ 2nd surgical site
◦ Violation of the normal facial nerve
89. Cross-facial Nerve Grafting
4 techniques
1. Sural nerve graft routed from
buccal branch of normal CN VII
to stump of paralyzed CN VII
2. Zygomaticus and buccal branch
of normal CN VII used to
reinnervate zygomatic and
marginal mandibular portions
respectively
3. 4 separate grafts from
temporal, zygomatic, buccal
and marginal mandibular
divisions of normal CN VII to
corresponding divisions on
paralyzed side.
4. Entire lower division of normal
side grafted to main trunk on
paralyzed side.
90. Muscle Transposition
(aka “Dynamic Sling”)
When to use:
Facial neuromuscular system absent
Neural techniques unsuitable
i.e. congenital facial paralysis
Facial nerve interruption of at least 3 years
Loss of motor endplates
Crossover techniques not possible due to donor
nerve sacrifice
91.
92. Muscle transposition most commonly employs the
temporalis muscle because of its good location,
length,contractility, and vector of pull.
good for reanimation of the mouth in patients with
long-standing (at least 1 year in length) paralysis.
Allows patients to have a voluntary smile.
Temporalis
93. Temporalis
Overcorrection at oral
commissure is critical
2nd or 3rd molar of upper dental
arch should be exposed when
procedure is finished
Harvest and placement of
temporoparietal facial flap
recommended to fill donor site
Oral support possible within 6
weeks
Movement achieved by clenching
the jaws
Unnatural contraction requiring
rehabilitation/Physiotherapy
94. Masseter
Used when temporalis muscle is not available
May be preferred due to avoidance of large facial
incision
Disadvantage:
Less available muscle compared to temporalis
Vector of pull on oral commisure is more horizontal
than superior/oblique like temporalis